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shelter verification form

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House Trailer Hotel/Motel Room Other Room Board meals included Commercial Rooming House Are meals included Y N Room in private home no meals - Is any part of rent used by landlord for heat/utilities Y N PERSONS RESIDING AT ABOVE ADDRESS/HOUSEHOLD COMPOSITION Date Tenant Moved In or Will Move In Name s of Persons s Responsible for Paying Rent Name s of Any Other Person s Paying Rent List All Persons Living at...

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House Trailer Hotel/Motel Room Other Room Board meals included Commercial Rooming House Are meals included Y N Room in private home no meals - Is any part of rent used by landlord for heat/utilities Y N PERSONS RESIDING AT ABOVE ADDRESS/HOUSEHOLD COMPOSITION Date Tenant Moved In or Will Move In Name s of Persons s Responsible for Paying Rent Name s of Any Other Person s Paying Rent List All Persons Living at...

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shelter verification form

Of this Agency. This form is for verification purposes only and does not imply any obligation on the part of this Agency. Please complete this questionnaire beginning with Section A below. Thank you for your cooperation. SECTION A SHELTER DESCRIPTION Type of Dwelling Check One Address Hotel/Motel Apartment City Room in Private Home Commercial Rooming House Are Meals Included Yes No House Zip Code Trailer No. of...

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