"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Please complete this form to verify the rental information for the tenant listed below. This form must be completed by the landlord or authorized property manager.

TENANT INFORMATION

Tenant Name*
Rental Property Address*

RENT INFORMATION

LANDLORD / PROPERTY MANAGER INFORMATION

PAYMENT INFORMATION

I, as the landlord or authorized property manager, agree to accept emergency financial assistance from the Outer Banks Relief Foundation (OBRF) on behalf of the tenant named above.

OBRF provides financial assistance to individuals and families who are experiencing a temporary financial crisis. Receipt of the approved payment will provide the tenant with 30 days of residency at the above rental property.
Mailing Address for Payment*

PROPERTY OWNERSHIP / AUTHORIZATION

Are you the owner of the rental property?*
If you are not the property owner, OBRF may require confirmation from the property owner that you are authorized to receive rental assistance funds. This requirement does not apply to licensed property management firms.

LANDLORD CERTIFICATION

By submitting this form, I certify that:
  • The information provided above is accurate and complete.
  • I am the landlord, property owner, or an authorized representative of the property owner.
  • I agree to accept the approved emergency assistance payment from the Outer Banks Relief Foundation.
  • I understand that receipt of the approved payment will provide the tenant with 30 days of residency at the rental property.
Name of Person Completing Form*
Electronic Signature*
Date*