Transcription of VT Landlord’s Certificate FORM Page 3 CLAIMANT: …
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VT Landlord’s Certificate FORM Page 3 CLAIMANT: …
Claimant s Last Name First Name Initial Claimant s Social Security NumberName of Owner or LandlordLandlord s Mailing Address City State ZIP CodeLocation of Rental Unit (number, street/road name) SPAN (from property tax bill) City / Town Number of Units in this BuildingRental Unit is (check one) Nursing Home / c Apartment c House c Lot for Mobile Home c Mobile Home c Boarding Home c Community CareItems Included in Rent (check all that apply)c Heat c Furnishings c Electricity c Personal Care c Other ServicesTenant #1 Last Name First Name Tenant #2 Last Name First NameTenant #3 Last Name First Name Tenant #4 Last Name First Name 1. Calendar year ..1a. _____ Number of months rented ..1b. _____ 2. Monthly rental amount paid ..2. _____ 3.
Claimant’s Last Name First Name Initial Claimant’s Social Security Number Name of Owner or Landlord Landlord’s Mailing Address City State ZIP Code
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