First Month's Rent Form

							                                         Ninth District Opportunity, Inc.
                                                   Community Action Agency



                                 First Month's Rent Form
 This letter is to confirm that                                                                                             has

arranged to rent an apartment/house from me effective

at                                                                                                                                          .

That I,                                                                                       , own the above property.

The amount of one month's rent is                          $                            which does not include deposits

or other fees.

COPY OF LEASE ATTACHED.

I agree to accept assistance from Ninth District Opportunity, Inc. for this payment of first month's rent.



X
Landlord Signature*                                                          Telephone Number


Street or PO Box                                                             Date

                                   ,GA
City                               State             Zip


* I understand that "A person who knowingly and willingly falsifies, conceals, or covers up by any trick, scheme, or device, a material fact,
or makes false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of State
Government, or of the government of any county, city or other political subdivision of this State shall be punished by a fine of not more
than $1,000 or by imprisonment for not less than one nor more than five years, or both." Georgia Code Annotated 26-2408. I declare to the
best of my knowledge the above information is true and this is an accurate statement. I authorize verification of any and all information on
this form.

For further information contact your Community Resource Coordinator at

            Stephens County NDO | P: 706-886-0211 | F: 706-886-7049 | E: stephens@ndocsbg.org


Verified by:                                                                                  Date:




First Month's Rent Form                                                                                                              FMR-09