LANDLORD VERIFICATION FORM

An application has been filed for financial assistance through the 2021 Cobb County Emergency Rental Assistance Program. Please
email this completed form and a copy of your W-9 to _____________________________. This form ensures precise check
processing.
Foini Maiava Tammy Brooks
I, ____________________________________________certify that________________________________________ has an existing
(Landlord Owner or Property Manager’s Name) (Print Tenant’s Name)
02/04/2023
residential lease with me, through this date ________________, and currently resides at the following address:

5450 BROOKWOOD DR SW, MABLETON GA 30126

__________________________________________

__________________________________________

Landlord Owner or Property Manager’s Phone Number: 907-2331-342 E-mail: Foinimaiava18@gmail.com

PAST DUE RENT

Amount of past due rent: $____________
1850 November 2021
for ________________ $____________
1850 for ________________
April 2022
(month) (month)

$____________
1850 December 2021
for ________________ 1850
$____________ june 2022
for ________________
(month) (month)

$____________
1850 February 2021
for ________________ $____________
1850 for ________________
July 2022
(month) (month)
$16,650
Total Rent Due:

Landlord Owner or Property Owner’s Name (as shown on W-9): Foini Maiava __________

Make check payable to: Foini Maiava

Mail check to (address): 423 W 22nd Ave, Apt 206, Anchorage , Alaska

________

Does the tenant receive any rental subsidies? Yes No If so: How much? What type?

Are you receiving any other form of rental assistance for this unit/household? Yes No

If so: How much? For what months?

Condition: The undersigned certifies that to the best of their knowledge the property referenced above
contains no health or safety violations that threaten the health or safety of the tenant.

Other Assistance: The undersigned certifies that they have not received rent payments from the Cobb County
Rental Assistance provider or any other program that covers the unpaid rent listed above.
No Eviction: 1) The undersigned agrees that they will not evict the tenant, provide the tenant with a Notice to
Quit, or in any way ask the tenant to leave for the duration of this assistance; 2) in the event the tenant is
facing eviction, the undersigned agrees a dispossessory action will not be filed for a period of thirty days if
funds are accepted from this program; and 3) if a dispossessory is pending, the undersigned agrees that it will
be dismissed within three days of receipt of funds from this program.

Relationship to Tenant: The undersigned certifies that tenant and owner/landlord are not immediate
relatives, through blood or marriage (i.e., child, parent, sister, brother, grandparent, aunt, uncle).

Relationship to Property Owner: The undersigned, if a property management company or legal

representative, certifies that it has the authorization to act on behalf of the property owner.

Attestation: In signing this statement (including electronic signature) I acknowledge that falsification of
documents or any material falsehoods or omissions in the Landlord Verification Form, including knowingly
seeking duplicative benefits, is subject to state and federal criminal penalties. I am on notice that 18 U.S.C.
§1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or
writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction
of any department or agency of the United States will be fined not more than $10,000 or imprisoned for not
more than five years, or both.

02.04.2023
______________________________________________
_______________________________
Landlord Owner or Property Owner’s Signature Date