CLAIM FOR RENTAL ASSISTANCE PAYMENT
PROJECT NAME PARCEL NO.
NAME(S) OF CLAIMANT
PRESENT MAILING ADDRESS
DATE MOVED INTO: Written Offer to Purchase Rec'd.
DATE MOVED INTO:
TYPE OF OCCUPANCY COVERED BY THIS CLAIM
Dwelling Unit Tenant ______Sleeping Room Tenant ______Homeowner Occupant
1. Monthly Rental of Comparable Dwelling
2. Monthly Rental of Replacement Dwelling
3. Monthly Rental of Dwelling Vacated
4. Monthly Replacement Rental Cost (Line 1 minus 3
OR Line 2 minus 3, whichever is less
5. Amount due Under This Claim (Line 4 multiplied
by 42, not to exceed $5,250)
I(We) CERTIFY, under th