Clear

VERIFICATION OF SHELTER EXPENSES
DCF Office Address/FAX #:

Date:___________________________________
Case Name:____________________________________________
Case Number:______________________
Please fill out this form to show how much you charge for rent for _______________________________________
and return the form to us by ________________________.

1. ________________________________________________ must pay me $______________ for:
Room and Meals each

Week or

Month or

Garbage

Other:__________________________________
Electric

2. Check any of these expenses that are included in the rent:

Rent or

Gas

Water

Sewer

Telephone

3. Does the renter pay or help pay to heat or cool the
home with an air conditioner, fireplace, or space heater? ............................
If No, does the renter pay for:

Electric

Gas

Water

Yes
Sewer

No
Garbage

Telephone?

4. This property is located at:_______________________________________________________________________
Give the full name of the person making the payment:_________________________________________________
5. What is the amount $______________ and date _______________ of last payment?
6. Is the payment past due?

Yes

No

If Yes, how much is past due? __________________________

7. How many adults __________ and how many children __________ live at this address?

For HUD or Section 8 Landlords Only:
8. How much is the rent after HUD or Section 8 deductions? $________________
9. Is a utility allowance paid?

Yes

No

If Yes, how much? $________________

What I have written on this form is true. I know if I write amounts that are not true on purpose, I could get
charged with fraud.

_____________________________________________________

______________________________________

Signature of Rent Collector / Landlord

Relationship to Renter

_____________________________________________________

______________________________________

Address

Telephone

_____________________________________________________

______________________________________
Date Completed

CF-ES 2622, PDF 03/2010

[65A-1.205, F.A.C.]

If applicable, enter "ext."
and extension number