CEMVP- - 03/98
CLAIM FOR RENTAL ASSISTANCE PAYMENT
PROJECT NAME PARCEL NO.
NAME(S) OF CLAIMANT
PRESENT MAILING ADDRESS
TELEPHONE NO.
OLD ADDRESS:
DATE MOVED INTO: Written Offer to Purchase Rec'd.
NEW ADDRESS:
DATE MOVED INTO:
TYPE OF OCCUPANCY COVERED BY THIS CLAIM
Dwelling Unit Tenant ______Sleeping Room Tenant ______Homeowner Occupant
COMPUTATION
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, unde