Wisconsin Rental Assistance Program (WERA)

Request for Assistance / Renter’s Verification

FORM TO BE COMPLETED AND SIGNED BY LANDLORD/RENTAL AGENT

This document is to be used in conjunction with the Renter Verification form to indicate the rental arrears and late fees owed by the
tenant. This form is to be completed and signed by the landlord/rental agent.

APPLICANT NAME Tony Fulk

UNIT ADDRESS 841 W Maple St
CITY, STATE, ZIP Flora IL 62839
PHONE NUMBER 8435085839
EMAIL ADDRESS Tonyf6125@gmail.com
WERA program may assist with unpaid rent/arrears as of March 13,2020 to the
current month and up to three additional months of assistance if determined
necessary to maintain housing. If the tenant receives rental assistance such as
section 8 or HUD housing, please indicate only what the tenant is responsible that
is
owed.
Mont Rental amount owed Late Fee owed
h
October 2020 $1000
November 2020 $1000
December 2020 $1000
January 2021 $1000
February 2021 $1000
March 2021 $1000
April 2021 $1000
May 2021 $1000
June 2021 $1000
July 2021 $1000
August 2021 $1000
September 2021 $1000

Total $ 12,000 $