LANDLORD REFERENCE FORM

HOUSING AND COMMUNITY DEVELOPMENT

LANDLORD REFERENCE FORM
Date

MonthDayYear
Date
Entity #:
HOH Name:
To whom it may concern:

The person named below has applied for housing assistance; therefore, it is necessary to conduct a landlord reference check. Your cooperation in supplying the information listed on this form in its entirety will be greatly appreciated.
THANK YOU FOR PROVIDING INFORMATION
I, (Type name) hereby authorize my current/previous landlord information requested below.

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
See attached Authorization to Release Information in lieu of signature above.

Attachment
Attached Authorization to Release Information:

Cancelof
THIS FORM MUST BE COMPLETED AND RETURNED VIA FAX TO HOUSING AND COMMUNITY DEVELOPMENT
ATTN:
HCD OFFICIAL OR REPRESENTATIVE
PHONE #:
Please enter a valid phone number.Format: (000) 000-0000.
APPLICANT NAME:
PROPERTYNAME:
Name of Landlord:
Status:

Current LandlordPrevious Landlord
Are you a relative or friend of the applicant?

YesNo
If YES, please describe relationship:
Date of Applicant's Tenancy: From Date to Date
Does (Did) the Applicant has a lease?

YesNo
Rent Payment
A. Amount of monthly rent (in $):
Balance Owed (in $):
Specify Month(s):
B. Has an eviction for non-payment of rent filed with the Clerk of the Court?

YesNo
B1. Was a court judgement rendered?

PendingYesNo
C. Has an eviction for any other reason filed with the Clerk of the Court?

YesNo
C1. Was a court judgement rendered?

PendingYesNo
Comment:
NAME OF PERSON COMPLETING FORM:
SIGNATURE OF PERSON COMPLETING FORM

Clear
TITLE
DATE

MonthDayYear
Date
PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
This material is available in an accessible format upon request to ada.coodinator@miamidade.gov
Should be Empty:

HOUSING AND COMMUNITY DEVELOPMENT