Form LDSS-3668 at a glance
What it is: Form LDSS-3668 SHELTER VERIFICATION is a questionnaire: the Agency needs information regarding household composition and shelter expenses to complete its evaluation of the assistance case.
Who signs: The landlord signs on the Landlord's Signature line and writes the Date.
A filled-in Form LDSS-3668 example: a landlord verifies a tenant's apartment
How to fill out Form LDSS-3668, box by box
Local District, Case Number and Worker ID
The top of the form has Local District Name and Address, Case Number, Worker ID and Case Name and Address.
Section A: Shelter Description
Write the shelter Address, City, Zip Code and County.
Under Type of Dwelling, check one: Hotel/Motel, Room in Private Home, Apartment (#), Commercial Rooming House (Are Meals Included? Yes or No), House or Trailer.
Write the No. of Bedrooms.
Mark Yes or No: Is any part of the room rent used for heat or utilities?
Section B: Household Composition
Write the Number of people living in this rental unit.
Write the Names, and how long each person has lived here.
Mark Yes or No: Does anyone listed in Section B have a telephone? Write the telephone Number.
Mark Yes or No: Is anyone listed in Section B employed? Write the Name and the Employer.
Mark Yes or No: Does anyone listed in Section B perform any services for you for which he/she receives a lower rent? If yes, explain.
Mark Yes or No: Do you have any employment opportunities for a member of this household? If yes, explain.
Section C: Shelter Expenses
Write the Rental Amount and check when it is Due: Weekly, Monthly, Every 2 weeks or Twice a month.
Mark Yes or No: Is rent paid up to date? Write the Last month that rent was paid in full.
Write the Name of person(s) paying rent. Write the Name of Tenant of Record if different from person paying the rent.
Mark Yes or No: Is rent subsidized? (e.g. HUD) If yes, write the amount subsidized and the Subsidizing agency.
Included in the rent, heating fuel and the furnace
Check the following which are included in the rent: Heat, Electricity, Hot Water, Air Conditioning, Furniture, Garbage Collection, Stove, Refrigerator, Water/Sewer, Cooking Fuel, Meals, Heating Equipment.
If heat is not included in rent, check the primary type of fuel used for heating: Natural Gas, Kerosene, Propane, Coal, Wood, Electricity or Oil.
Check what the furnace/stove heats: Only this apartment, Entire House or Other (Specify).
Amounts the tenant pays, separate meters and anyone outside the household
Mark Yes or No: Does the tenant pay to you an amount, separate from the rent, for heat or air conditioning? If yes, list the monthly amount. If no, mark Yes or No: does the tenant pay the vendor directly for heat?
Mark Yes or No: Does the tenant pay to you an amount, separate from the rent, for water? If yes, list the monthly amount.
Mark Yes or No: Does the tenant pay to you an amount, separate from the rent, for other non-heating utilities? If yes, list the monthly amount.
If tenant pays for non-heating utilities, mark Yes or No: are there separate meters for the tenant's apartment?
Mark Yes or No: To your knowledge, does anyone that lives outside of the household pay all or part of the rent and/or utilities? If yes, please explain.
Section D: Landlord Information
Write the Date Tenant moved in / will move in.
Mark Yes or No: Does Landlord live in the same apartment/ rental unit as tenant?
Write the Relationship to Tenant, the Landlord's Name, the Landlord's Address and the Landlord's Telephone Number.
The landlord's signature, Date and the Owner
The landlord signs on the Landlord's Signature line and writes the Date.
Write the Landlord's E-mail Address.
Write the Owner's Name if different than landlord.
Write the Owner's Address, Owner's Telephone Number and Owner's E-mail Address.
More rules for Form LDSS-3668
Please complete this questionnaire beginning with Section A.
This form is for verification purposes only, and does not imply any obligation on the part of the Agency.
Sources
[1] Form LDSS-3668 (Rev. 11/15), Shelter Verification, New York State Office of Temporary and Disability Assistance (the Official source link on this page).