Form W-146E LLF
Rev. 12/3/09
Date:
Case Number:
Case Name:
|
Request to Pay Rent Arrears in Excess of Cash Assistance Maximum Shelter Allowance |
I, |
|
, am requesting assistance to pay rent arrears to avoid eviction. |
|
(Name) |
I understand that my rent is in excess of the cash assistance maximum shelter allowance for my household size.
I understand that in order to have this request approved, I must provide documentation showing how future rent payments will be made, including a statement from a third party who will help me pay my rent.
I understand that the rent arrears payment will be made in the form of a check made payable to my landlord.
If any of the rent arrears advanced to me duplicates assistance previously given to me by the Human Resources Administration, I agree to the recoupment of such portion of the arrears payment.
Applicant/Participant's Signature:Date:
Agreement by Third Party to Pay Excess Rent
I, |
|
, affirm that: |
|
|
|
|
|
|
(Name) |
|
|
|
|
|
|
|
I agree to pay the excess rent in the amount of $ |
|
|
for the apartment occupied |
by |
|
|
at |
|
|
, |
|
|
|
( App lican t / Par t icip an t ' s Nam e) |
|
|
|
|
( Ap plican t / Par t icipan t ' s Ad dr ess) |
effective |
|
. The payment will be made directly to the: |
cef aforementioned applicant/participant cef landlord (name and address):
My income, indicated below, is sufficient to meet all of my expenses as well as the excess rent payment.
My monthly household income is:My shelter expense is: The proof of income I am submitting is:
cef Pay stubs, W-2 form and/or letter from employer on employer's stationery from:
(Employer's Name and Address)
cef Proof of other income/source:
My relationship to the applicant/participant is:
My address is:
The above information is true and correct.
Signature:Date: