Tenant Certification. I attest that the information stated above is true and accurate and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate application termination and/or could result in penalties as specified by law. In addition, I agree to allow [NAME OF ADMINISTERING AGENCY] to release the above information to the water provider as necessary to process payment and verify services provided. In addition, I agree that data from this form (not including my personal identifying information) may be used for reporting or program evaluation purposes. Tenant Signature Date
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Sources: Landlord Agreement, Landlord Agreement
Tenant Certification. I attest that the information stated above is true and accurate and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate application termination and/or could result in penalties as specified by law. In addition, I agree to allow [NAME OF ADMINISTERING AGENCY] Comprehensive Community Action Program to release the above information to the water provider as necessary to process payment and verify services provided. In addition, I agree that data from this form (not including my personal identifying information) may be used for reporting or program evaluation purposes. Tenant Signature Date.
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