Landlord Payment Form

Before You Begin

Please complete this form only if a WYO HELP-supported program has asked you to provide landlord payment information for a tenant.

The organization you select below will receive the completed Landlord Payment Request. Submission of this form does not guarantee payment.

W-9 Required Before Payment

A current W-9 must be on file with WYO HELP or the organization administering WYO HELP-supported assistance before payment can be issued. W-9 and ACH banking information are handled separately and should not be entered on this form.

1. Select the Organization

Select the organization that asked you to complete this form.

Administering Organization *

Program-Year Assistance Limit

WYO HELP payment assistance through this program is limited to $1,000 per household during the program year. Previous WYO HELP-supported assistance received by the household may reduce the amount currently available.

I understand that the household may receive no more than the applicable WYO HELP program-year limit.

If the amount due exceeds $1,000, what should WYO HELP know? *

2. Tenant & Rental Information

Provide the information for the tenant receiving assistance.

Tenant First Name *

Tenant Last Name *

Rental Street Address *

City *

State

ZIP Code *

County *

Type of Home

Rent Due Date *

Rental Period Covered

Amount Due *

Enter the amount needed to prevent eviction or bring the household current.

If Paid, Rent Will Be Current Through

3. Landlord / Property Manager

Landlord or Property Manager Name *

Business or Property Management Company

Phone *

Email *

4. Payment Information

A current W-9 must be on file before payment can be issued.

Is a current W-9 already on file? *

Preferred Payment Method *

5. Duplicate Assistance Certification

WYO HELP-supported funds cannot be used to pay an expense that has already been paid, or will be paid, by another organization, program, insurance source, or other funding source.

I certify that, to the best of my knowledge, the amount requested on this form does not duplicate assistance already received or committed from another source. *

6. Landlord Certification & Signature

By signing below, you certify that the information provided is true and accurate and authorize verification of the tenancy, amount due, rental period, and other information necessary to review this payment request.

Printed Name *

Title / Relationship to Property

Signature Date *

Signature *

Sign inside the box using your mouse, finger, or stylus.

Payment Request Submitted

The Landlord Payment Request has been sent to the organization administering the tenant's WYO HELP-supported assistance.

Remember that a current W-9 must be on file before payment can be issued.