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NH Department of Health and Human Services DHHS Division of Family Assistance DFA RENTAL VERIFICATION REQUEST DFA Form 775 12/13 To be completed by the landlord or Housing Authority if subsidized. TO FROM Centralized Scanning Unit P. House etc. Mobile home lot HUD 236 No Subsidy Other Specify Rent amount charged to tenant How often Weekly This amount has been charged since Twice per month Every two weeks Signature and Title of Landlord Manager or Housing Official Monthly Date Print Name of Landlord Manager or Housing Official Address Telephone PLEASE SEE INSTRUCTIONS ON BACK DFA SR 13-03 4YC How To Complete This Form This form is used by the NH Department of Health Human Services to collect rental verification information. Please complete the entire form beginning with the section titled PLEASE COMPLETE THE FOLLOWING INFORMATION and return it by the date requested in the first section. Thank you. O. Box 181 Concord NH 03301 Tenant s name Tenant s mailing address Street Apt City State Zip We would appreciate rental information concerning this tenant. The information is necessary in order to determine his/her eligibility for benefits. Please complete the following information and return to the address noted above by Thank you for your cooperation* PLEASE COMPLETE THE FOLLOWING INFORMATION Name s of the person s responsible for paying the rent Rental unit s street address Date occupancy began Is the rent current Number of Adults Yes No What is included in the rent Number of Children If not what is the amount of arrearage Heat Utilities COMPLETE FOR SUBSIDIZED HOUSING ONLY What type of subsidized housing is this FHA 515 Housing Choice Voucher Program formerly Section 8 Conventional Public Housing Other Deep Subsidy Specify What is the gross family contribution per month What is the net family contribution per month These amounts have been effective since Does this tenant pay excess usage fees for heating cooling COMPLETE FOR ALL OTHER TYPES OF HOUSING NON-SUBSIDIZED What type of non-subsidized housing is this Apt. 1. Fill in the name s of the person s liable for rent street address of the housing unit apartment number date that occupancy began the number of adults occupying the rental unit the number of children occupying the rental unit whether the rent is current the amount of arrearage if the rent is NOT current and whether heat and/or utilities are included in the rent. 2. If the housing unit is subsidized check the appropriate box indicating the type of subsidized housing the tenant is occupying indicate whether or not the tenant incurs an excess heating or cooling cost fill in the gross and net family contributions and fill in the date that these amounts went into effect. fill in the amount of rent that is charged to the tenant 4. Sign and date the form* 5. Print your name address and telephone number. O. Box 181 Concord NH 03301 Tenant s name Tenant s mailing address Street Apt City State Zip We would appreciate rental information concerning this tenant. The information is necessary in order to determine his/her eligibility for benefits. Please complete the following information and return to the address noted above by Thank you for your cooperation* PLEASE COMPLETE THE FOLLOWING INFORMATION Name s of the person s responsible for paying the rent Rental unit s street address Date occupancy began Is the rent current Number of Adults Yes No What is included in the rent Number of Children If not what is the amount of arrearage Heat Utilities COMPLETE FOR SUBSIDIZED HOUSING ONLY What type of subsidized housing is this FHA 515 Housing Choice Voucher Program formerly Section 8 Conventional Public Housing Other Deep Subsidy Specify What is the gross family contribution per month What is the net family contribution per month These amounts have been effective since Does this tenant pay excess usage fees for heating cooling COMPLETE FOR ALL OTHER TYPES OF HOUSING NON-SUBSIDIZED What type of non-subsidized housing is this Apt.