Notice of Rent Due

Note: This form must be completed no sooner than five days prior to rent due date.

Tenant Information

Names of All Adult Tenants

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Your rent is due on what day of each month?

YYYY

You owe (or will owe) rent for the month(s) of:

Total rent currently owed:

Landlord Information

As a landlord, I have previously worked with Christ Community Church

Select

Yes

Manager/Landlord Name

First Name

Last Name

Representing (Owner/Company Name)

First Name

Last Name

If approved, the rent check should be made payable to:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landlord Phone #

(###)

###

####

Rent Payee for Payment

NOTE: Requests for rent will be required to return the "Notice of Rent Due" form.

By signing, I am stating that the information I have provided is true and accurate. The C3 Community Care team has my permission to verify any information that I have reported on this application.

Applicant Digital Signature

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landlord Digital Signature

First Name

Last Name

Note: Completing this form is not a guarantee of Christ Community Church assistance. If C3 agrees to assist with rent, the landlord must agree not to pursue any eviction action for 30 days after receipt.