PLEASE ATTACH A COPY OF YOUR DRIVER'S LICENSE

Fort Pierce Housing, Inc. · Each Adult (18 or older) must fill out a separate application
Affordable Housing · There is a non-refundable fee of $25.00 at time of application for a
Rental Application credit check to be performed per adult. FPHA has the right to deny
an application based on the results of the credit check or any
All areas of this application must be completed before it can be processed. misleading information.

Driver's License # & State (WE WILL NEED A COPY OF YOUR

First Middle Last Birth Date Social Security # DRIVER'S LICENSE.)

Any Other Names You've Used In the Past Contact Telephone Number Alternate Telephone Number

All Other Proposed Occupants Birth Date Social Security Number Relationship to Applicant

RENTAL/RESIDENCE HISTORY
Information in this Section will be verified directly with the source.
Current Residence Previous Address Prior Residence
Street Address

City
State & Zip
From/To Date
Last Rent Amount Paid
Owner/Manager
and Phone Number
Reason for Leaving
Own/Rent?

Is/Was Rent Paid in Full?

Did You Give Notice?

Were You Asked to Move?

Name(s) in Which Your
Utilities Are Registered:
EMPLOYMENT HISTORY/INCOME INFORMATION
Information in this Section will be verified directly with the source.
Current Employment Previous Employment Prior Employment

Employer
Street Address

City

State & Zip

From/To Date

Current Hourly Rate of Pay

Supervisor and Contact

Number
Number of Hrs. Worked Per
Week

Reason for Leaving

___________________ __________________________ _________________________________________ _______________________

Date Received Received By Proposed Address Move In Date

____________________ _________________________ ____________________________________________________________________________________________________________

Security Deposit Amount Paid Rent Amount Comments

 OTHER INCOME
(All income must be disclosed, including Child Support, Social Security, Social Security Disability, Pensions, Food Stamps, Welfare,
Cash, Contributions, etc.)
Type Amount Name of Recipient Pay Periods

BANKING INFORMATION
Institution Name Checking Account Number Savings Account Number Other

VEHICLES (Include all vehicles that will be on premises)

Make Model Color Year License Plate Name Vehicle Registered In

OTHER INFORMATION
Have you ever been convicted of a felony? Have you ever filed for bankruptcy? If so when?
Do you have any recurring problems with your current apartment or
Have you ever been arrested or convicted of any crime? landlord? If yes, please explain:

Have you ever been served a late notice? Do you understand that there are no pets allowed?
Have you ever been served an eviction notice?
If so when? Is there any reason you may be denied?

Why are you moving from your current address? When are you planning to move in?

Do you currently have renter's insurance?

REFERENCES REFERENCES EMERGENCY CONTACTS

Name Name Name

Street Address Street Address Street Address

City City City

State & Zip State & Zip State & Zip

Phone Number Phone Number Phone Number

Relationship to Applicant Relationship to Applicant Relationship to Applicant

Agreement & Authorization Signature

Applicant certifies that all of the statements and representations are true and complete, and hereby, authorizes verification of the above information, references and credit records. Applicant understands that
an investigative consumer report including information about character, credit history, general reputation, personal characteristics, mode of living, and all public record information including criminal records
may be made. Applicant agrees that false, misleading or misrepresented information may result in the application being rejected, will void a lease/rental agreement if any and/or be grounds for immediate
eviction with loss of all deposits and any other penalties as provided by the lease terms if any. Applicant authorizes verification of all information by the Fort Pierce Housing Authority (FPHA). Applicant has
the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation. NON-REFUNDABLE APPLICATION FEE--
Applicant(s) has paid to FPHA herewith the sum of _______ as a NON-REFUNDABLE APPLICATION FEE for costs, expenses and fees in processing the application. SECURITY DEPOSIT AGREEMENT--
Applicant has deposited a SECURITY DEPOSIT of $_______ in consideration for taking the dwelling off the market while the application is being processed. If applicant is approved by FPHA and the lease
is entered into and possession of the dwelling is taken, the "SECURITY DEPOSIT" shall be applied toward security/damage deposit. If applicant is approved, but fails to enter into the lease within three (3)
days of verbal and/or written approval and/or take possession after lease signing, the FULL "SECURITY DEPOSIT" shall be forfeited to FPHA in addition to any penalties as provided in the lease if the lease
has been signed by the applicant. The "SECURITY DEPOSIT" shall be refunded only if applicant is not approved. Keys will be furnished only after lease and other rental documents have been properly
executed by all parties and only after applicable rentals and security deposits have been paid. This application is preliminary only, in no way implies that a particular rental unit shall be available and in no
way obligates FPHA to execute a lease or deliver possession of the proposed premises.

I HAVE READ AND AGREE TO THE PROVISIONS AS STATED

Applicant Signature Date

By signing the application you grant us permission to communicate with all the contacts listed i in the event we cannot locate you. Missing, incomplete, false or misleading information will deem this
application ineligible for rental.

First Months Rent

Application Fee $ $
Total due Before
Security Deposit $ Move In $

Paid With Application

$
Approved For
Balance of Deposit Due
$ Move In

Approved By