W-147Q (E) 11/02/2018 (page 1 of 2) LL
F
Date:
Case Number:
Case Name:
Center Number:
Verification of Secondary Tenant's
Residence and Housing Costs
A "primary tenant" is a person listed on a lease or rental agreement who shares with,
or rents that apartment/house (or a room) to, another person called a "secondary tenant."
Primary Tenant's Name: Secondary Tenant's Name:
1. I share with, or rent an apartment/house (or room) to, the secondary tenant named
above.
2. I am the primary tenant of that apartment/house, which is located at:
(print address below)
Street Apartment Number Town/State Zip Code
3. The secondary tenant lives in this apartment/house with the family members of
their household: (print names below)
4. The secondary tenant pays $ in monthly rent.
5. The secondary tenant pays the rent to: (check one) the landlord to me
(Turn Page)
W-147Q (E) 11/02/2018 (page 2 of 2)
LLF
Human Resources Administration
Family Independence Administration
6. The secondary tenant's rent is paid to (must include address):
Name
Street Apartment Number Town/State Zip Code
7. Does the secondary tenant pay an amount separate from the rent for heating or air
conditioning? Yes No
If no, does the secondary tenant pay an amount separate from the rent for other
utilities that are not heating or air conditioning? Yes No
8. My telephone number is :
9. Attached is a copy of my lease or other documents proving that I am the
primary tenant.
I affirm under penalty of perjury that the information I have given on this form is correct and
complete to the best of my knowledge.
Signature of Primary Tenant Date
