5D
ONEIDA COUNTY DEPARTMENT OF SOCIAL SERVICES
Anthony J. Picente Jr
800 Park Ave
County Executive
Utica, NY 13501
Colleen Fahy-Box
Commissioner
LANDLORD STATEMENT
TENANT NAME:
This agency requires the completion of this landlord statement for verification of residency and living expenses/arrangements
of the above tenant. This entire form must be completed, in ink, by the landlord (or an authorized agent) only! Both tenant
and landlord must sign the back of this form. The rental unit is subject to inspection.
A. Shelter Description
Type of dwelling:
Apartment
Street Address
Apt/Floor
Single House
Double House
Hotel/Motel Room
City/Town
County
Zip Code
Room in Private Home
Tenant will be occupying dwelling effective:
Commercial Room
OR
Other
Change in expenses / occupants effective:
B. Shelter Expenses
Do you charge rent or room and board? Rent Room and board
If you charge rent for a room, is any part of it used for Heat or Utilities? Yes No
Please subtract Items 2, 3, and 4
from item 1, if applicable. This
will give you a total for item 5.
This is the amount the tenant is
potentially entitled to. This is also
the amount that is potentially
eligible for a TRA.
1. How much total rent is charged for the dwelling?
$
2. Subsidy from Section 8 or other H.U.D. Agency
$
3. Subsidy from
$
4. Contribution from person outside the household
$
5. Amount tenants are responsible for (see instructions at left)
$
Rent Includes (Check Yes or No for every item)
Heat
Yes No
Water/Sewer
Yes No
Furniture
Yes No
Electric
Yes No
Kitchen Stove
Yes No
Prepared Meals
Yes No
Cooking Fuel
Yes No
Refrigerator
Yes No
Cooking Equip.
Yes No
Is the heat source shared with another dwelling?
Yes No
Check the type(s) of fuel used to heat the unit:
Are any other utilities shared with another dwelling?
Yes No
Natural Gas
Oil/Kerosene
Electricity
Propane
Wood
Please Note that every item in this section must be completed (even if the answer is “No” or rent payments may not
be made correctly.
C. Household Composition
Please list all members of the dwelling unit, even if not applying for assistance. List the designated tenants(s) of record first
(the person(s) legally responsible for the dwelling, who would sign a rental agreement).
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
Total number of persons living in the rental unit:
Is anyone in the dwelling employed?
Yes No
If Yes:
Tenant’s Name
Business Name
PLEASE CONTINUE ON THE REVERSE SIDE OF THIS FORM
D. Landlord Information
This section must be completed in full. Please provide a phone number where the landlord and/or property manager may be
reached during normal business hours (between 8:30 AM and 4:30 PM).
Name (please print)
Phone #
Address
Fax #
Is the property managed by an individual other than the landlord? Yes No If Yes:
Name (please print)
Phone #
E. For Restricted Payments
This department can make rental payments directly to the landlord in the form of a two-party check. This check requires both
the landlord and tenant signatures in order to be cashed. The tenant must be entitled to the full shelter allowance. In some
cases, the tenant must also agree below, in writing.
In cases where a property manager is unable to sign a two-party check on behalf of the landlord, an alternative may be
available. Please contact your tenant’s examiner to discuss your options.
If the tenant’s case is closed or the tenant moves and you are receiving restricted rent payments, you will be notified by this
department of when they will cease. The tenant is obligated to give you 30 days notice when this occurs. This department
will notify you before the date the rent payments will cease whenever possible.
I agree to have the rent sent directly to my landlord: Yes No
Landlord’s signature
Date
Tenant’s signature
Date
Does shelter meet all municipal Codes requirements?
Yes No
Landlord’s Social Security/Federal ID#
(Required for restricted payments)
If yes, date Certificate of Occupancy issued:
F. Notice to Landlord
This statement is for verification purposes only. It does not constitute an agreement between this agency and the property
owner. The tenant is solely responsible for rent payments, damages, lease provisions, and 30-day notice prior to a move.
Oneida County cannot be responsible for rent payments if client moves without a 30-day notice. This agency must be
immediately notified in writing when and if any change, such as amount of rent or number of occupants, occurs.
The landlord may request a Tenant Responsibility Agreement (TRA) in place of a security deposit. To do so, they may
contact the Oneida County DSS Housing Unit by phone at (315) 798-3661 or by email at [email protected] . This request
must be made within 30 days of the date of occupancy. The tenant or landlord may also contact the Housing Unit to request
housing information or for help completing this form.
G. Certification/Verification by Subscriber and Notice
I, the undersigned, hereby certify that the information in this landlord statement is true and correct and that this form was
completed by the landlord before being signed.
As the tenant, I agree to give the landlord 30 days notice prior to a move. I understand that failure to comply with the 30 day
notice provisions as required may result in a delay or withholding of my benefits.
As the landlord, I declare that all real estate taxes on subject property have been paid to date, and further acknowledge that
future rent payments will be withheld if real estate taxes are not paid in a timely manner.
Landlord’s signature
Date
Tenant’s signature
Date
Property Owner’s signature
Date
This space for DSS use only
Date Received:
Information verified per phone call to landlord/manager?
Yes No
If No, Shelter Verification mailed:
Worker:
TA-10 Landlord Statement (Rev. 2/08)
