Emergency Rent Assistance Program Landlord Statement/Ledger of Rent Due Use this form to create a rent and fees statement to use to request past due rent and fees owed to your landlord back to March 13, 2020. Please note: By completing this form, a landlord is providing a statement that the following information is true. Completing this form allows us to process rent assistance more quickly. Date Completed: Landlord Name: Property Name: Landlord contact information (phone and/or email): Tenant Name: Address of tenant, including unit number: Move-in or lease dates: Please verify that the tenant listed about is paying rent to a lease holder. _______________________________________________________________________________ _______________________________________________________________________________ __________________has been living at______________________since____________________. This person___________________________owes $____________ per______________ for rent. Fees included in this statement are for: They are currently behind in rent and fees payable to the landlord as of: DATE Month, Year Total Rent Rent Paid by Tenant Month, Year Rent Owed Rent Paid Rent Paid by Other Program Rent Paid Fees Due Total Due/Outstanding Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed Month, Year Rent Owed Rent Paid Rent Paid Fees Due Amount Needed I certify that the information provided in this document is true and accurate to the best of my knowledge. I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may result in denial of the application, repayment of any funds received through the RentHelpMN program, or other remedies available under law. Signature: ___________________________________________Acrobat PDFMaker 21 for Word Adobe PDF Library 21.5.90