Get MA Shared Housing Verification Form 2015

Shared Housing Verification Form Instructions Part I to be completed by the requester enter your name and the date the form must be returned. enter the name and address of the head of the household sharing housing expenses with the person named in Part III and enter the date the person moved in. NOTE Complete the Requester Use Only box when the completed form is returned. Part III The Authorization to Release Information must be fully completed. Please complete the following Question 1. Answer yes or no for each question* If the answer is yes always fill out the Amount. many meals per week and Amount paid for these meals. Question 3 4 y 5. Answer yes or no for each question* Question 6. Number of Households at this address. Question 7. Please list the names of the people who live with the person named in Part III who also live in your household. For the head of household completing this form please print your name sign and date the bottom of the form* Once it is completed keep the yellow copy for your records and give the white copy to the person named in Part III of this form* Requester Name Authorization to Release Information Name of head of household sharing expenses with the person named in Street Address City/Town Print Name give permission to the requester to obtain and verify this information* ZIP Signature Date Date person named in Part III moved in // Part IV TO BE COMPLETED BY THE HEAD OF THE HOUSEHOLD SHARING EXPENSES WITH THE PERSON NAMED IN PART III. The person named in Part III pays Rent/mortgage H yes H no Amount per heat H yes H no If yes what is the type of heat electric H yes H no gas oil telephone water sewerage trash/garbage removal H yes other Specify a* rents a room b. gets meals provided REQUESTER USE ONLY What is the SUA H Heating Nonheating H Phone Prorate Divide SUA by of households If yes how many meals per week Amount paid for these meals is Is anyone in your family related to the person named in Part III Do you purchase and prepare meals together Do you live in Public Housing Section 8 or Massachusetts Rental Voucher Program Housing How many households live at the address in Part II Names of household members including person named in Part III. Answer yes or no for each question* If the answer is yes always fill out the Amount. many meals per week and Amount paid for these meals. Question 3 4 y 5. Answer yes or no for each question* Question 6. Number of Households at this address. Question 3 4 y 5. Answer yes or no for each question* Question 6. Number of Households at this address. Question 7. Please list the names of the people who live with the person named in Part III who also live in your household. Question 7. Please list the names of the people who live with the person named in Part III who also live in your household. For the head of household completing this form please print your name sign and date the bottom of the form* Once it is completed keep the yellow copy for your records and give the white copy to the person named in Part III of this form* Requester Name Authorization to Release Information Name of head of household sharing expenses with the person named in Street Address City/Town Print Name give permission to the requester to obtain and verify this information* ZIP Signature Date Date person named in Part III moved in // Part IV TO BE COMPLETED BY THE HEAD OF THE HOUSEHOLD SHARING EXPENSES WITH THE PERSON NAMED IN PART III.