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Aid To Distressed Families of Appaladhiall Counties(ADFAC) Room 103,First Presbyteian Church Post OnEce Box 5953,Oak Rldge,1 37831

Phone:865 483-6028

Fax 865-483-2697

Name of Tenant:

Address of Tenant:

Amount of Rent Tenant Pays Per Month: $ (Fill out below if other source ofrent) HUD Assistance $ HUD Utili Assistance S
Date Rent Payment is Due:

{ro",

Tenant Owe More Than One Month?


Has Tenant l,eased From You?

$(

no* r.ng

Landlord: Please Yerifu the above i4formation. I *rtlfy th" .b^. It t" be accurate and true. I am in no way related to the above said tenant. By gr a slg47 f t V 6 b` `6 ` S & 2C , R ss` ptt 7b D,s 7 O
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Client is responsible for remaining rent in the amount of

'

$-

VICaS / IS , DF tt

may

` fax ADFAC at 865-483-2697.

Signature of Owner or Agent

Check Payable to

Marling Street Address

Ci"

State

Zip Code

Phone Number

Date

Q::12 9 : : 3 0 O B 595`,O R'dg,73

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