Dshs Form Landlord PDF Details

The Department of Social and Human Services (DSHS) requires all landlords who rent to clients receiving housing assistance from the department to complete a Form Landlord. Completing this form is mandatory for landlords and is used to ensure that only eligible tenants receive rental assistance from DSHS. In this blog post, we will provide an overview of the Form Landlord, including what information is required, how to complete it, and why it is important. We will also provide tips for landlords who are completing the form for the first time. Stay tuned – we'll have more blog posts on landlord topics in the near future! Thanks for reading!

QuestionAnswer
Form NameDshs Form Landlord
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdshs 14 224, po tenant zip download, how to dshs 14 224, landlord statement forms sample

Form Preview Example

 

 

 

 

LOCAL OFFICE

 

 

TELEPHONE NUMBER

 

 

STATEMENT FROM

 

 

 

 

 

 

CLIENT IDENTIFICATION NUMBER

 

 

DATE

 

 

LANDLORD/MANAGER

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY OWNER OR AUTHORIZED MANAGER:

 

 

The Department of Social and Health Services is in the

 

 

 

 

process of determining this client’s eligibility. Please provide

 

 

Complete all sections below with only the information

 

 

 

 

 

 

the information requested below.

 

 

 

 

 

you know to be true. Write “unknown” to questions you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

can’t answer. (Do not leave any box blank.)

 

 

FINANCIAL SERVICES SPECIALIST’S SIGNATURE

 

 

 

 

 

 

 

 

 

 

A. Rental or leased unit and tenant information:

1.

STREET ADDRESS

APARTMENT (APT) NUMBER

 

 

5. NAMES OF ALL ADULTS AND CHILDREN LIVING AT THIS ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

TENANT’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

DATE MOVED IN

4. TYPE OF RESIDENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach more pages if needed.

 

 

 

 

 

 

 

 

 

 

 

 

B. Rent information:

 

 

 

 

 

 

 

 

 

 

 

6.

TOTAL RENT AMOUNT

7. HOUSING AGENCY AMOUNT, IF ANY

8. TENANT’S RENT AMOUNT

 

9. DATE THE AMOUNT IN BOX 8 STARTED

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. NAME OF PERSON(S) PAYING THE RENT

 

 

11. NAME OF PERSON(S) PAYING THE RENT

 

 

 

 

 

 

 

 

 

 

12. PLEASE ANSWER THE FOLLOWING QUESTIONS:

 

 

 

 

 

 

 

 

 

Does the tenant pay only a portion of the amount in box 8?

No

Yes, amount: $

 

 

 

Does the tenant work for a portion of the amount in box 8?

No

Yes, amount: $

 

 

 

 

 

 

 

 

 

 

Number of hours worked per month: __________

How does the tenant pay the rent?

Cash

Check/Debit Card

Money Order

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Utilities information: Mark the box(es) that apply.

13. The main source of heating for this residence is:

Electric Wood

Gas

Propane Other (specify):

YES NO

14. Is there a separate meter for gas and electric?

15. Does the tenant pay for air conditioning?

16. Are all utilities included in the rent?

Yes

If NO, mark the box(es) the tenant pays for:

Electric

Water/sewer

 

Gas

Telephone

 

Propane

Garbage

 

Wood

 

 

Other (specify):

No

17. LANDLORD/MANAGER’S NAME

 

 

 

18. Property Owner’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If different from Landlord/Manager)

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS OR PO BOX NUMBER

 

 

 

OWNER’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

 

ZIP CODE

 

STREET ADDRESS OR PO BOX NUMBER

 

 

 

 

 

 

 

 

 

 

 

WORK TELEPHONE NUMBER

 

 

HOME TELEPHONE NUMBER

 

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

LANDLORD/MANAGER SIGNATURE

 

DATE

 

WORK TELEPHONE NUMBER

 

HOME TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

DSHS 14-224 (X) (REV. 06/2010)

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