Landlord Form County – Fill Out and Use This PDF

At Landlord Form County, we take pride in providing our customers with quality links to various filling forms related to rental displacement documents. Our rental eviction and land leasing documents are designed to help connect landlords with tenants by documenting the policies that will guide the flow of the property. Additionally, our tenant credit check links offer users a simple way to check current ratings and review history records. All of our forms and processes are efficient, and comply with every relevant state legal codes. Led by experienced professionals and managed by certified professionals, Landlord Form County is a one stop destination for user friendly forms that help maintain a safe community setting while ensuring responsible landownership.

Landlord Form County PDF Details

Are you a landlord looking to become an expert in form county law? With the ever changing landscape of tenant/landlord laws, it can be tough to keep up with the changes. Fortunately for landlords, there are plenty of resources available that can help guide them through landlord-tenant laws in form county. In this post we will discuss some tips on navigating and understanding these regulations, so that you can confidently take control of your rental properties!

Question	Answer
Form Name	Landlord Form County
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	monroe county dss landlord statement, nys landlord statement form, landlord statement for snap, chemung county landlord statement

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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 #
Name of tenants	Relationship		Source 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.

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

How to Edit Landlord Form County Online for Free

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So as to fill out this PDF document, ensure you enter the information you need in every blank:

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

It is easy to get it wrong while filling in the Attention Property Owner Please, for that reason be sure to look again prior to when you finalize the form.

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Landlord Form County – Fill Out and Use This PDF

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