"Section 8 Utility Account Certification Form - Gastonia Housing Authority" - North Carolina

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GASTONIA HOUSING AUTHORITY
SECTION 8
UTILITY ACCOUNT CERTIFICATION FORM
Instructions: This form must be completed and given to your caseworker prior to being housed. All
blanks must be completed.
Make sure you have this form available when calling the utility company so that you can fill in the
information for Date services was turned on and Utility account number. If you fail to completely fill out
this form you will not be housed.
Tenant’s (Head of Household) Name: ____________________________________________________________
Tenant’s new address:
(Address where service was turned on)___________________________________________________________
Please complete one entry below for each utility you will be responsible for (power, gas, water, trash
collection. Do Not include telephone, cable, etc.)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
ALL UTILITY ACCOUNTS MUST BE IN THE HEAD OF HOUSEHOLD’S NAME.
Failure to maintain utility service in the head of household’s name may result in the termination of
housing assistance.
By signing below, I certify that the information provided by me in this document is true and complete.
________________________________
_____________________
Tenant Signature
Date
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS
GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT
STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES GOVERNMENT.
F:\DATAFILE\Housing Programs\Section 8 Program\FORMS\Utility Verification Form REVISED 070731.doc
GASTONIA HOUSING AUTHORITY
SECTION 8
UTILITY ACCOUNT CERTIFICATION FORM
Instructions: This form must be completed and given to your caseworker prior to being housed. All
blanks must be completed.
Make sure you have this form available when calling the utility company so that you can fill in the
information for Date services was turned on and Utility account number. If you fail to completely fill out
this form you will not be housed.
Tenant’s (Head of Household) Name: ____________________________________________________________
Tenant’s new address:
(Address where service was turned on)___________________________________________________________
Please complete one entry below for each utility you will be responsible for (power, gas, water, trash
collection. Do Not include telephone, cable, etc.)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
Name of Utility Provider Company ____________________________________________________________
Date service was turned on: ___________________ Utility account number: ____________________________
(IMPORTANT: You must get this information from the utility company when you have utility turned on)
ALL UTILITY ACCOUNTS MUST BE IN THE HEAD OF HOUSEHOLD’S NAME.
Failure to maintain utility service in the head of household’s name may result in the termination of
housing assistance.
By signing below, I certify that the information provided by me in this document is true and complete.
________________________________
_____________________
Tenant Signature
Date
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS
GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT
STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES GOVERNMENT.
F:\DATAFILE\Housing Programs\Section 8 Program\FORMS\Utility Verification Form REVISED 070731.doc