Franklin County Board of Commissioners * \\ JOB & FAMILY FCDJFS Housing Assistance Need Form veo: SERVICES Purpose: The tenant named below has applied for housing essistance from Franklin County Department of Job & Family Services {herein FCDJFS or Franklin County). In adherence with program rules, FCDIFS Is required to obtain verification of the tenant's need and payment remittance information. It is also required that you as the landlord/property owner, agree to the terms and conditions set forth in this form and provide the requested information and/or documents. Doing so allows FCDIFS to process and make timely payments, Fallure to do so will delay payment or may resultina denial ofthis request. Tenant: Address: city: State: RENT: the rent amount indicated here must match the amount listed in the current lease agreement. FCDIFS requires @ copy of the lease. An official ledger may be submitted if additional space is needed. This section may be used for prospective rent if applying for ERA or PRC PLUS funds, as long as those funds are avaliable. Monthly Portion Tenant | Remaining Amt Notes Amount Pai Due Month Due Date ‘Total Amount of Rent Requested: | $ UTILITIES INCLUDED IN RENT: To be considered as partof the rent, the lease must specify which utlty is included and how itis to be aid. A utility addendum is acceptable. ‘Monthly | Portion Tenant Notes Roan bats Remaining Amt Due Month Due Date Total Amount of Utilities Requested | § (OTHER FEES: Notall fees are eligible for payment. Requests must fal within allowable program criterla, Portion Tenant | Remaining Amt Notes: Paid Due ‘Type of Fee Month Due Date Total Amount of Foes Requested: | $ ‘Amount of Total Request: §, FCDJFS 3800-C Housing Assistance Need Form Page 1of2Torms of Attestation and Agreement by the Landlord/Property Owner/Property Manager: © understand that this form is not a guarantee of payment, ‘+ Lunderstand that program staff will review ll information provided to determine the tenant's eligibility and what, if any, assistance can be approved. ‘© [confirm all the information and documentation provided are complete, accurate, and current. ‘© agree to accept housing assistance funds from Franklin County and abide by the terms and conditions set forth in this form, agree that the funds provided will be used only for the intended purposes of the program. ‘© agree that should a payment be made for rent arrears It will be considered as payment in full. Any pending eviction for this amount wil be dismissed or that! will fle a motion to vacate an eviction judgement within 30 days of receiving payment. | further agree that | will not file an eviction on this tenant for non-payment for atleast the 30-day perlod following the payment by Franklin County, ‘© | agree that should a payment be made for prospective rent; this payment will secure housing for this tenant for atleast the time covered under this payment, ‘© agree that should the tenant vacate the property prior to the time covered under the payment, a refund will be made to Franklin County for the portion of time the tenant was not in the property. | agree that should | receive a duplicate payment for this tenant for rental arrears or prospective rent | shall return the payment to Franklin County. ‘© understand that a W9 Form is requited for payment. If Franklin County has a correct and current W9 Form on file a new form may not be required. | understand any missing or incorrect information on the WS Form may delay payment or result Inthe denial of a payment. It is imperative the name and tax! number on the submitted W9 Form match IRS records. AGREEMENT TO PARTICIPATE: By signing below, I, the landlord or legal representative, certify that | understand and agree to the terms ofthis form. Signature: Printed Name: PAYMENT REMITTANCE: f approved for assistance the payment wil be mailed to the address provided below. This company name ‘must match the name on the Lease and the W9 Form. f there isa property management agreement in place FCDIFS will need a copy of itand the property manager’s W9 Form. ‘Company Name: Complex Name (if applicable) Phoné Address: city: State: Zip Cod Contact Person: Contact Phon Email Address: REFUSAL TO PARTICIPATE: If you refuse to participate in this program, we are required to document such. Please complete the following Statomer {refuse to participate in the program Nam Position/Title Email: Signature: Date: The completed form and any other required documentation can be submitted by the tenant or you, at [email protected] Information on all Financial Assistance Programs can be found on our website at: Emergency Assistance [PRC] - Franklin County Department of Job and Family Services (franklincountyohio.pov) FCDIFS 3800-C Housing Assistance Need Form Page 2 of 2