Public Records Verification 5-year addresses

HOUSING AND COMMUNITY DEVELOPMENT

PUBLIC RECORD VERIFICATION
Entity #:
Name of Head of Household:
Name of co-head, spouse, or domestic Partner:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Move-in Date:

MonthDayYear
Date
No Record of EvictionsRecord of Eviction printed and attached
NoYes
If yes, address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Approved:

Clear
Disapproved:

Clear
Date:

MonthDayYear
Date
Print Name:
Official Use Only - Eligibility Interviewer Completes:
ReviewedLive with family/friends
NoYes
Amount ($):
NoYes
If yes, list household members/ in Elite Notes
NoYes
NoneRecord Exists
Approved:

Clear
Disapproved:

Clear
Date:

MonthDayYear
Date
Print Name:
This material is available in an accessible format upon request to ada.coordinator@miamidade.gov
Should be Empty:

HOUSING AND COMMUNITY DEVELOPMENT