Rent Review Request Form

Licking Metropolitan Housing Authority · Housing Choice Voucher Program
144 W. Main St., Newark, OH 43055 · Ph: 740-349-8069 · Fax: 740-349-7132

Information in This Area for Property Owner

Tenant Name

Unit Address

Unit Type

Bedroom Size

Current contract rent

$

Requested new rent

$

Date rent increase to start

Reason for rent increase

Owner-paid utilities

Gas Electric Water & Sewer Trash Range Refrigerator

Tenant-paid utilities

Gas Electric Water & Sewer Trash Range Refrigerator

Tenant utility change

Gas Electric Water & Sewer Trash Range Refrigerator

Do you supply the range and refrigerator?

Yes No

Owner Name

Owner Address

Owner Phone

Owner signature

Date

For LMHA Use Only — Increase Decision Form

This block is completed by LMHA staff only.