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Rental Information Agreement

2. City of Westbrook Rental Information Agreement
   (This form must be completed in its entirety.)
   Notice to Landlord: The City of Westbrook’S Code Enforcement Department will now be inspecting all housing units prior to the general assistance office authorizing payment on an applicant’s behalf.<br><br>Please provide complete and accurate contact information so that the inspection can be set up and completed in a timely manner.

   Notice to Landlord: The City of Westbrook’S Code Enforcement Department will now be inspecting all housing units prior to the general assistance office authorizing payment on an applicant’s behalf.
   
   Please provide complete and accurate contact information so that the inspection can be set up and completed in a timely manner.

4. Tenant's First Name

5. Last Name

7. Date
   Date

9. Address

11. City

12. State

13. Zip Code

15. Apartment Number

16. Number of Bedrooms

18. Landlord Information

20. First Name

21. Last Name

23. Phone Number

24. Email

26. Unit Manager Information
    If other than above.

    If other than above.

28. First Name

29. Last Name

31. Business Phone

32. Cell Phone

34. Email

36. Apartment Information

38. Rent Amount Weekly

39. Monthly

41. Is a security deposit required?

    1. Yes
    2. No

    If the City pays a security deposit, the entire deposit must be returned to the City of Westbrook within 21 days (or within a 30-day window, if lease indicates a 30-day security deposit return) after the tenant moves out indicating amount being returned. (A security deposit cannot be kept for “normal wear and tear”.)

42. Amount

44. What utilities are included in the rent?

    1. Water / Sewer
    2. Hot Water
    3. Electric
    4. Heat
    5. Gas for Cooking

45. How is the unit heated?

    1. Electric
    2. Gas
    3. Oil
    4. Other

47. Please explain.

49. Is the listed tenant occupying this unit?

    1. Yes
    2. No

50. If no, when is this unit available?

52. Number of persons occupying this unit?

53. Names of people sharing apartment/house?

55. Is handicap access required for anyone in this household?

    1. Yes
    2. No

56. Term of Lease

58. Any Relationship to tenant?

    1. Yes
    2. No

59. If yes, how?

61. Landlord Electronic Signature

63. I certify that the above-referenced unit has been inspected and there are no deficiencies:

65. Code Enforcement Official

66. Date
    Date

68. Notice:
    This Rental Information Agreement is not intended to imply that the prospective tenant is either eligible for assistance or that they will necessarily be renting an apartment from you. All rental payments are made directly to the Landlord, not the tenant. Applicants receive a written decision stating whether or not assistance has been granted. A purchase order is provided for the landlord. <br><br>City of Westbrook General Assistance phone is 207-854-0676, ext. 5280.

    This Rental Information Agreement is not intended to imply that the prospective tenant is either eligible for assistance or that they will necessarily be renting an apartment from you. All rental payments are made directly to the Landlord, not the tenant. Applicants receive a written decision stating whether or not assistance has been granted. A purchase order is provided for the landlord.
    
    City of Westbrook General Assistance phone is 207-854-0676, ext. 5280.

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

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