Deposit Assistance Program
____________________________________________ has been approved for occupancy
(applicant)
at ______________________________________________ provided that the required
(rental
unit address)
Security Deposit in the
amount of $____________is paid in full by ____________________________.
(date the deposit is due)
Approved occupants age 18
years and older include:
_____________________________ ______________________________
_____________________________ ______________________________
The anticipated date of move in is _______________________________.
The total monthly rental amount for this unit is _____________________.
LANDLORDS:
YOUR SIGNATURE AT THE BOTTOM OF THIS FORM GUARANTEES THAT YOU HAVE READ AND AGREE TO THE FOLLOWING CONDITIONS:
I am willing to accept all or partial security deposit for this unit from the Central Iowa Regional Housing Authority. I agree that any amount of the required security deposit not provided by CIRHA is the responsibility of the tenant. I understand that if approved for security deposit assistance, the tenant will provide me with a CIRHA Deposit Assistance voucher stating the amount that will be paid by CIRHA and the date the actual check will be mailed to me. I understand that this deposit assistance is part of a grant program and that any and all future refund of this security deposit will be paid directly to the tenant. I also understand that the Central Iowa Regional Housing Authority carries no responsibility for the actions (financial or otherwise) of the occupants and/or occupant’s guests. All claims for unpaid rent or damages are the sole responsibility of the tenant.
CHECK MADE PAYABLE TO______________________________________________
MAILING ADDRESS _____________________________________________________
TELEPHONE NUMBER _____________________________________________________
____________________________________________ ____________________
LANDLORD/COMPANY
REPRESENTATIVE SIGNATURE DATE
_______________________________ ____________________________________
PRINT NAME OF SIGNATORY TITLE OF
SIGNATORY
Please return this form to the applicant or CIRHA.
CIRHA
1201 Gateway Drive Fax: (515)
986-1883
Grimes,