BFA Form 775 "Rental Verification Request" - New Hampshire

What Is BFA Form 775?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of BFA Form 775 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

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Download BFA Form 775 "Rental Verification Request" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 775
Bureau of Family Assistance (BFA)
10/19
RENTAL VERIFICATION REQUEST
(To be completed by the landlord or Housing Authority, if subsidized.)
TO:
FROM:
Centralized Scanning Unit
P.O. Box 181
Concord, NH 03301
Tenant’s name:
Tenant’s mailing address:
Street
Apt#
City
State
Zip
We would appreciate rental information concerning this tenant.
The information is necessary in order to determine his/her eligibility for benefits. Please complete the following information
and return to the address noted above by
Thank you for your cooperation.
PLEASE COMPLETE THE FOLLOWING INFORMATION
Name(s) of the person(s) responsible for paying the rent:
Rental unit’s street address:
Street
Apt. #
City
State
Zip
Date occupancy began:
Number of Adults:
Number of Children:
Is the rent current?
Yes
No
If not, what is the amount of arrearage? $
What is included in the rent?
Heat:
Yes
No
Utilities:
Yes
No
COMPLETE FOR SUBSIDIZED HOUSING ONLY
What type of subsidized housing is this?
FHA 515
Housing Choice Voucher Program
(formerly Section 8)
Conventional Public Housing
Other Deep Subsidy (Specify)
What is the gross family contribution per month? $
What is the net family contribution per month? $
These amounts have been effective since:
Does this tenant pay excess usage fees for heating?
Yes
No
cooling?
Yes
No
COMPLETE FOR ALL OTHER TYPES OF HOUSING (NON-SUBSIDIZED)
What type of non-subsidized housing is this?
Apt., house, etc.
Mobile home lot
HUD 236 (No Subsidy)
Other (Specify)
Rent amount charged to tenant: $
This amount has been charged since:
How often?
Weekly
Twice per month
Every two weeks
Monthly
Signature and Title of Landlord, Manager or Housing Official
Date
Print Name of Landlord, Manager, or Housing Official
Address
Telephone
BFA SR 19-29
PLEASE SEE INSTRUCTIONS ON BACK
(4YC)
NH Department of Health and Human Services (DHHS)
BFA Form 775
Bureau of Family Assistance (BFA)
10/19
RENTAL VERIFICATION REQUEST
(To be completed by the landlord or Housing Authority, if subsidized.)
TO:
FROM:
Centralized Scanning Unit
P.O. Box 181
Concord, NH 03301
Tenant’s name:
Tenant’s mailing address:
Street
Apt#
City
State
Zip
We would appreciate rental information concerning this tenant.
The information is necessary in order to determine his/her eligibility for benefits. Please complete the following information
and return to the address noted above by
Thank you for your cooperation.
PLEASE COMPLETE THE FOLLOWING INFORMATION
Name(s) of the person(s) responsible for paying the rent:
Rental unit’s street address:
Street
Apt. #
City
State
Zip
Date occupancy began:
Number of Adults:
Number of Children:
Is the rent current?
Yes
No
If not, what is the amount of arrearage? $
What is included in the rent?
Heat:
Yes
No
Utilities:
Yes
No
COMPLETE FOR SUBSIDIZED HOUSING ONLY
What type of subsidized housing is this?
FHA 515
Housing Choice Voucher Program
(formerly Section 8)
Conventional Public Housing
Other Deep Subsidy (Specify)
What is the gross family contribution per month? $
What is the net family contribution per month? $
These amounts have been effective since:
Does this tenant pay excess usage fees for heating?
Yes
No
cooling?
Yes
No
COMPLETE FOR ALL OTHER TYPES OF HOUSING (NON-SUBSIDIZED)
What type of non-subsidized housing is this?
Apt., house, etc.
Mobile home lot
HUD 236 (No Subsidy)
Other (Specify)
Rent amount charged to tenant: $
This amount has been charged since:
How often?
Weekly
Twice per month
Every two weeks
Monthly
Signature and Title of Landlord, Manager or Housing Official
Date
Print Name of Landlord, Manager, or Housing Official
Address
Telephone
BFA SR 19-29
PLEASE SEE INSTRUCTIONS ON BACK
(4YC)
How To Complete This Form
This form is used by the NH Department of Health & Human Services to collect
rental verification information. Please complete the entire form beginning with the
section titled, PLEASE COMPLETE THE FOLLOWING INFORMATION, and
return it by the date requested in the first section. Thank you.
1. Fill in:
the name(s) of the person(s) liable for rent;
street address of the housing unit;
apartment number;
date that occupancy began;
the number of adults occupying the rental unit;
the number of children occupying the rental unit;
whether the rent is current;
the amount of arrearage if the rent is NOT current; and
whether heat and/or utilities are included in the rent.
2. If the housing unit is subsidized:
check the appropriate box indicating the type of subsidized
housing the tenant is occupying;
indicate whether or not the tenant incurs an excess heating or
cooling cost
fill in the gross and net family contributions; and
fill in the date that these amounts went into effect.
3. If the housing unit is non-subsidized:
check the appropriate box indicating the type of non-subsidized
housing the tenant is occupying;
fill in the amount of rent that is charged to the tenant;
check the appropriate box indicating how often rent is due; and
fill in the date that this amount went into effect.
4. Sign and date the form.
5. Print your name, address and telephone number.
6. Return this form to the Central Scanning Unit at the address in the first
section.
This institution is an equal opportunity provider.
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