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2. City of Westbrook Rental Information Agreement
   (This form must be completed in its entirety.)
   Notice to Landlord: The City of Westbrook’S Code Enforcement Department will now be inspecting all housing units prior to the general assistance office authorizing payment on an applicant’s behalf.
   
   Please provide complete and accurate contact information so that the inspection can be set up and completed in a timely manner.
4. Tenant's First Name
5. Last Name
7. Date
   Date
9. Address
11. City
12. State
13. Zip Code
15. Apartment Number
16. Number of Bedrooms
18. Landlord Information
20. First Name
21. Last Name
23. Phone Number
24. Email
26. Unit Manager Information
    If other than above.
28. First Name
29. Last Name
31. Business Phone
32. Cell Phone
34. Email
36. Apartment Information
38. Rent Amount Weekly
39. Monthly
41. Is a security deposit required?

    1. Yes
    2. No

    If the City pays a security deposit, the entire deposit must be returned to the City of Westbrook within 21 days (or within a 30-day window, if lease indicates a 30-day security deposit return) after the tenant moves out indicating amount being returned. (A security deposit cannot be kept for “normal wear and tear”.)
42. Amount
44. What utilities are included in the rent?

    1. Water / Sewer
    2. Hot Water
    3. Electric
    4. Heat
    5. Gas for Cooking
45. How is the unit heated?

    1. Electric
    2. Gas
    3. Oil
    4. Other
47. Please explain.
49. Is the listed tenant occupying this unit?

    1. Yes
    2. No
50. If no, when is this unit available?
52. Number of persons occupying this unit?
53. Names of people sharing apartment/house?
55. Is handicap access required for anyone in this household?

    1. Yes
    2. No
56. Term of Lease
58. Any Relationship to tenant?

    1. Yes
    2. No
59. If yes, how?
61. Landlord Electronic Signature
63. I certify that the above-referenced unit has been inspected and there are no deficiencies:
65. Code Enforcement Official
66. Date
    Date
68. Notice:
    This Rental Information Agreement is not intended to imply that the prospective tenant is either eligible for assistance or that they will necessarily be renting an apartment from you. All rental payments are made directly to the Landlord, not the tenant. Applicants receive a written decision stating whether or not assistance has been granted. A purchase order is provided for the landlord.
    
    City of Westbrook General Assistance phone is 207-854-0676, ext. 5280.
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field