PUBLIC HOUSING AND COMMUNITY DEVELOPMENT

LANDLORD REFERENCE FORM

Date

Entity #:

HOH Name:

To whom it may concern:

The person named below has applied for housing assistance; therefore, it is necessary to conduct a landlord reference check. Your

cooperation in supplying the information listed on this form in its entirety will be greatly appreciated.

THANK YOU FOR PROVIDING INFORMATION

I, hereby authorize my current/previous landlord information requested below.

Signature: _______________________________________________ Date:

See attached Authorization to Release Information in lieu of signature above.

THIS FORM MUST BE COMPLETED AND RETURNED VIA FAX TO PUBLIC HOUSING AND COMMUNITY DEVELOPMENT

FAX #:

ATTN:

PHCD OFFICIAL OR REPRESENTATIVE

PHONE #:

APPLICANT NAME: PROPERTY NAME:

Name of Landlord: ____________________________________________ Current Landlord Previous

Landlord

Are you a relative or friend of the applicant? Yes No - If YES, please describe relationship:

Dates of Applicant’s Tenancy: From to

Does (Did) the Applicant has a lease? Yes No

Rent Payment

A. Amount of monthly rent: $ Balance Owed: $

Specify Month(s):

B. Has an eviction for non-payment of rent filed with the Clerk of the Court? Yes No

B1. Was a court judgment rendered? Pending Yes No

C. Has an eviction for any other reason filed with the Clerk of the Court? Yes No

C1. Was a court judgment rendered? Pending Yes No

Comment:

NAME OF PERSON COMPLETING FORM:

SIGNATURE OF PERSON COMPLETING FORM TITLE DATE

PHONE NUMBER: FAX NUMBER: