DUPLICATION OF BENEFITS FORM: APPLICANT
Date:__________________________________________________________
Client Name:____________________________________________________
Client Name(roommate/significant other):______________________________
Please mark the box below regarding any prior assistance:
● NO , I/we have not applied for or received any funding assistance for rent, mortgage or
utilities from another agency in the past 12 months. Initial_________ Initial_________
● YES , I/we have applied for or received funding assistance for rent, mortgage or utilities
from another agency in the past 12 months. Initial_________ Initial_________
If YES, please list name of the organizations, amount received and the months paid:
Name:_________________________________________________________________
Requested $_____________ Received $_____________ Month(s) paid_____________
Name:_________________________________________________________________
Requested $_____________ Received $_____________ Month(s) paid_____________
Name:_________________________________________________________________
Requested $_____________ Received $_____________ Month(s) paid_____________
● Are there any applications pending from other agencies at this time?
NO : Initial_________ Initial __________
YES : Initial_________ Initial __________
If YES , please list name of agency and Date applied:
Name____________________________________ Date:_________________________
CERTIFICATION : I certify that the information that I have provided above is an accurate and
complete disclosure. I understand that to perjure myself in order to obtain assistance is a
fraudulent offense for which I can be prosecuted.
Client Signature:_________________________________________________________
Client Signature(roommate/significant other): __________________________________
Date:__________________________________________________________________