RENTAL VERIFICATION

Your LANDLORD must complete this information: Instructions to LANDLORD (property manager/agent): Please answer each question below; check appropriate areas; sign and date below. THIS IS NOT A CONTRACT OR LEASE. If necessary, someone may contact you for additional information. Be sure to read this form carefully before completing and signing it. Anyone who makes false statements to obtain or help another person obtain assistance, for which they are not eligible, is subject to penalties under the laws of the State of Wyoming. Completion of this Rental Verification form is required to be considered for LIEAP and WAP program approval. I also authorize the Department to openly discuss and share all information regarding a client’s case with the client’s Authorized Representative should client elect to appoint one. Supplier hereby authorize release of information concerning LIEAP application and benefits as necessary for payment, to prevent shutoff, or to obtain fuel consumption, fuel usage, fuel type, annual fuel cost, and payment history data for LIEAP and/or weatherization purposes. Name of Tenant

Rental Address: (Include Apartment or Lot Number)

Type of Rental unit:

House

Apartment

Mobile Home

OTHER (specify):

Do you as a Landlord provide a Utility Allowance in the lease agreement? If yes, amount of Utility Allowance $ ______________

Yes

No

Rent includes the following utilities paid for by the landlord, but are not reimbursed back to the landlord by the tenant: Check ALL that apply: Natural Gas

Propane

Electricity

Wood/Pellets

Coal

Home Heating Oil

Other

Coal

Home Heating Oil

Other

Renter must pay the following utilities. Check ALL that apply: Natural Gas

Propane

Electricity

Wood/Pellets

What is the Main heating source? This is the fuel the heat system uses to heat the home, not the power source needed to turn on the furnace. Natural Gas

Propane

Electricity

Wood/Pellets

Coal

Home Heating Oil

Other

Rent is increased from ____________ to ____________ during November – June for the Main heating source utilities paid for by the landlord that are reimbursed back to the landlord by the tenant. Landlord (property manager/agent) Name (Please Print) Landlord (property manager/agent) Address

Phone:

Landlord (property manager/agent) Signature

Date:

Questions? Call 1-800-246-4221

Revised 06/09/15