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1/2/16 Human Resources Administration Family Independence Administration Landlord's Claim for Security Voucher Payment I (we), the Landlord(s) of the premises described on page 1 of this form, certify that tenant/participant name has vacated the apartment located at Apt. on or about address and occupied the date apartment within three months prior to the date of this certification. I hereby request that the security voucher be paid to me for the reason specified below: Tenant/Participant.

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