Landlord Form County PDF Details

In the realm of housing and social services, the Department of Human Services Landlord Statement stands out as a pivotal document, designed to streamline the communication and procedural requirements between landlords, tenants, and the supporting governmental body. This form addresses various scenarios such as new moves, additions, rent increases, and more, by requiring detailed information about the tenant, their case number, and specifics of the dwelling including the move-in date and the amount of monthly rent. In its essence, it not just facilitates clarity on financial aspects like the client's share of the rent and if the rent includes utilities, but also delves into the living arrangements by listing all residents. Furthermore, it outlines the responsibilities of tenants, particularly highlighting that they remain accountable for rent and must inform the landlord about vacating. The form also touches upon the scenarios involving security deposits and requests for the Department of Social Services (DSS) to directly pay the rent, thereby encapsulating the necessities that govern landlord-tenant interactions in subsidized housing contexts. Notably, the form includes directives for landlords in case of health and safety violations and the requirement for a move-in inspection when a Landlord Tenant Security Agreement is sought, ensuring that both parties are protected. Completing this form with accuracy and care is crucial for ensuring the welfare and legal rights of all involved parties are upheld, reflecting a comprehensive approach to managing landlord-tenant relations within the framework of social services.

QuestionAnswer
Form NameLandlord Form County
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmonroe county dss landlord statement, nys landlord statement form, landlord statement for snap, chemung county landlord statement

Form Preview Example

DEPARTMENT OF HUMAN SERVICES LANDLORD STATEMENT

 

 

 

I/EDR:05

 

Please check one:

 

 

TO BE COMPLETED BY LANDLORD

 

 

 

□ New Move

 

THIS IS NOT A CONTRACT -

ALL QUESTIONS MUST BE ANSWERED

 

 

 

□ Add On

 

 

 

 

 

 

□ Rent Increase

 

 

 

 

□ Other: _________

 

 

 

 

 

Client name (print):______________________________ Case Number: ___________________ Move in Date:_____________

 

Address of Property:_________________________________________City/Town:__________________ State: _____ Zip: __________

Check type of Dwelling

 

 

 

 

 

 

 

 

Apartment (#_______)

 

House

Amount of Monthly Rent $________ Client’s Share $_________

Hotel/Motel

 

 

Trailer

If Increase, effective Date _______________________________

Rooming House

 

Room in Private House

Is rent past due?

Yes

No If yes, how much: _________

 

Check the items below that ARE included in the rent:

If heat is NOT included in rent check, type of FUEL used:

Heat

Water/Sewer

 

 

Natural Gas

Wood

 

 

Electric

Cooking Fuel

 

 

Electricity

Oil

 

 

Stove

Refrigerator

 

 

Propane

Other __________________________

Furniture

Meals # __________

Separate Meter for each apartment?

Yes

No

Does Furnace Heat:

Apartment Only or

Entire House?

 

 

 

 

 

Is Rent Subsidized?

No

Yes

 

Name of Subsidizing Agency __________________________________________________

Name of Person Paying Rent _______________________________________ Total number of people residing in dwelling _______

List ALL Residents in Property – (even if that tenant is not applying)

Name of tenants

Relationship

How long they have lived there?

Type of income/

Case #

 

Source of income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE TENANT IS AND REMAINS RESPONSIBLE FOR PAYMENT OF RENT.

DHS IS NOT RESPONSIBLE FOR NOTIFYING THE LANDLORD OF A TENANT’S INTENTION TO VACATE THE PROPERTY.

IT IS THE TENANT’S RESPONSIBILITY TO NOTIFY THE LANDLORD WHEN VACATING THE PROPERTY.

Have you accepted a cash security deposit?

Yes

No

 

 

Are you requesting a DSS Landlord/Tenant Security Agreement?

Yes (*Please read the directions on the back of this form)

Are you requesting rent be paid directly by DSS?

Yes (Vendor # _____________)

No

If you have any questions, you may call our Landlord Hotline at (585) 753-6034. / To Obtain a Vendor Number, Call: 753-6663.

No

Property owner’s name (print) __________________________________________________ Day Phone ______________________

Landlord/Authorizing Agent Signature ___________________________________________________ Date ___________________

Address ______________________________________________________________________ Day Phone _____________________

City ________________________________ State ____________ Zip __________________ Evening Phone ____________________

Client Signature __________________________________________ Date _________________Day Phone _____________________

If anyone other than the Property Owner, you MUST supply a copy of the Management Agreement, LLC, Trust or other authorizing paperwork outlining who is authorized to sign and receive rents. The LL Statement will not be processed without this information.

 

 

- THIS SECTION FOR DEPARTMENT USE ONLY -

Violations RGE UVR

UTX

Assessor Address Split L/L Contacted

Landlord/Tenant Approved Y N

Type of Dwelling Sgl

Mult

If no, why? ____________________________________________________

Date Received _________________________________ Unit/Worker ___________________________________________________

MCDSS-236 (Rev 5/11)

Page 1 of 2

Address of Property:_________________________________________City/Town:__________________ State: _____ Zip: __________

Case Number:

Attention Property Owner

Please note that rent and/or a Landlord Tenant Security Agreement (LTA) can not be authorized if the premises has been cited for health and safety violations.

If you are requesting a Landlord Tenant Security Agreement (LTA) a Move-in inspection is required when an LTA is being used to secure the premises against Client/Tenant caused damages. You may schedule a Move-in inspection up to 14 days in advance of the anticipated move in date. If for some reason your prospective tenant does not move in the inspection will be valid for 30 days.

To schedule an inspection contact:

For properties located within the City of Rochester - Contact the Housing Council at their website at www.RocLandlords.com, or by phone at (585) 546-3700- ext. 3010

For properties located outside of the City of Rochester – Contact KMS Home Inspection, Inc. at www.kmshomeinspection.com, or by phone at (585) 766-7722.

If your request for an LTA is approved the Client/Tenant’s worker will send you two (2) copies of the LTA. Once you have secured the Client/Tenant’s signature on the LTA a copy should be given to the Client/Tenant

and the original should be retained for your records. If it becomes necessary to file a claim on this agreement you will need to send a copy of this form in with your claim. Please do not send a copy of the LTA to this Department until you are filing a claim for unpaid rent and/or damages.

Please note that the Landlord Tenant Security Agreement is not valid unless the Client/Tenant has signed the Landlord Tenant Security Agreement.

MCDSS-236 (Rev 5/11)

Page 2 of 2

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1. The chemung county landlord statement requires specific information to be inserted. Make certain the subsequent blank fields are finalized:

How one can fill in landlord statement county pdf portion 1

2. Just after filling out this section, head on to the next part and complete the essential particulars in these blank fields - THE TENANT IS AND REMAINS, DHS IS NOT RESPONSIBLE FOR, IT IS THE TENANTS RESPONSIBILITY, Have you accepted a cash security, Yes, Are you requesting a DSS, Yes Please read the directions on, Are you requesting rent be paid, Yes Vendor, Address Day Phone, City State Zip Evening Phone, and Client Signature Date Day Phone.

landlord statement county pdf completion process outlined (stage 2)

3. In this specific step, check out Address of PropertyCityTown State, Case Number, MCDHS is a National Voter, registration form can be mailed to, and Attention Property Owner Please. These should be filled in with utmost awareness of detail.

Filling in section 3 in landlord statement county pdf

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