mma FRE Use OHH POLK COUNTY BOCC coset: HOUSING & NEIGHBORHOOD DEVELOPMENT LANDLORD VERIFICATION POLK NOTICE TO TENANT: DATE: Your signature hereby authorizes your landlord to release the b Tenant's Legal ot ‘or Type) DEAR LANDLORD: Name of Tenant “Tenant's Address has applied for rental assistance from Polk County's Housing & Neighborhood Development (HND) Office. In order to determine eligibility, the below information is required. Please type or print legible to avoid processing delays. fav'p Signature (REQUIRED) 4. Tenant’s move-in date:____J_ Rentispaid through__/__/__ Please provide the delinquent amount due $. How many bedrooms are in the rental unit?_ Please lis the base rent for this unit, as stated on the lease, excluding all other fees Are you receiving any other payments or rent subsidy for this tenant, such as Section8/HUD? Yes_No_ |s the tenant residing in an affordable housing program unit (income-based for low-income)? Yes___No__ Is the amount of rent for this tenant determined based on income? Yes__No__ 6. if yesto any, the tenant is not eligible for services, PLEASE DO NOT PROCEED with the completion of thisform, 7. iftenantis determined eligible, will you accept payment as written in the lease agreement? Yes_No___ 8 Isthe tenant related to you? Yes_No_If yes, explain relationship 9. Are you employed by Polk County? Yes. No___ If yes, please list department. Polk County, Housing & Neighborhood Development Office will only authorize payments to the verified owner or property Management Company, stated below and on a valid, corresponding W-9 form. Please fax to 863-534-0349 or email to HNDRequest@polk-county.net. Staff are required to complete the verification process in a short time period and would appreciate your prompt response. (Owner/Property Management, as stated on Substitute W-9, including DBA ‘Owner/Property Management Company's Physical Address (PO Box not acceptable) City FL_— Zip Code ‘Owner/Property Management Representative Mailing Address (Payment address) City FL Zip Code (Owner/Property Management Representative Phone Cell/work Owner/Property Management Rep email address attest that | havea lease agreement with the above named tenant. ‘© Iwill allow Polk County's HND Office inspect my rental property to assure it meets standards. ‘Iwill continue to maintain this dwelling and assure it meets standards for the duration of the rental assistance from Polk County. (Owner/Property Management Representative Signature ‘Owner/Property Management Representative (Print Name) Form Created 07/31/20 *See reverse side for more information