Economic Opportunity Community Empowerment,

505 Hamilton Street . ohio o 43604-8520 . 419 242 7304 , 419 &63. hflp;7fiwt^^/

Landlord Form
This form is to be completed by the property owner or ar,rthorized person
and returned to
Pathway. I

TenanUCustomer Name: l

Properly Address:
1,,

t:

City State zip

(Completing this form does not guarantee payment t approval.
This form is part
of the housing process that a c ustomer must com
).
Please complete the table below indicatin g the months a d amounts
past due
t Charge Type
Month (i.e. late rent, late Amount Owed
court

Total
l, ( La n dl o rd/o rgan izati on name)
amount provided by Pathwav for the above tenant to co agree to accept the
expenses hack from April 1,
2020. I further agree to not increase the rent costs prior receipt of CARES Act, CDBG-
CV Home Relief Grant and/or CAA Home Relief or to evict the tenant for
nonpayment for the months covered through this program.

Landl ord/Agent SiEnature Date

Landlo rdlOrganization Printed Name Telepho Number

(Who should check be m;de payable to?)

Mailing Address Email Ad rESS

City State Zip Landlord lN or Social Security Number

Mission Statement Pathway reduces poverfy by providing comprehensive :hat create pathways to self-sufficiency,