Rental Application

Applicant:
Name: __________________________________________________________________________
Current Address: __________________________________________________________________
City, State, Zip Code: __________________________________ Work Phone: ________________
Home Phone: ___________________ Social Security # _______________________________
Date of Birth: ___________ Bedroom Size Requested: ________ e-mail Address:____________________
Marital Status: ____ single ____ married ____ divorced ____ separated ____ widow

Co-Applicant:
Name: ___________________________________________________________________________
Current Address: ___________________________________________________________________
City, State, Zip Code: __________________________________ Work Phone: _________________
Home Phone: _________________ Social Security # ______________ Date of Birth: ____________
Marital Status: ____ single ____ married ____ divorced ____ separated ____ widow

HOUSEHOLD COMPOSITION AND CHARACTERISTICS

1. List the Head of Household and all other members who will be living in the unit. Give the Relations of each
family member to the head.

Name Relationship Birth Age Sex Social Security Student

Date circle which
applies
Head of Household NO FT PT
NO FT PT
NO FT PT
NO FT PT
NO FT PT
NO FT PT
NO FT PT
2. Do you expect a change in your household composition within the next 12 months?  Yes  No
If yes, please explain: ___________________________________________________________

STUDENT STATUS:
Are all of the residents full time students? () Yes () No
If yes: is the household comprised of a single parent and child,
Neither of who is dependent on a third party. () Yes () No
If yes: is Applicant & CO-Applicant married and file a joint tax Return? () Yes () No
If yes: does the household receive AFDC or TANF? () Yes () No
If yes: is head of household in federal or state job training program? () Yes () No

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INCOME INFORMATION
Please answer each of the following questions. For each “yes,” provide details in the charts below.
Does any member of your household:

1. Work Full time, part time, or seasonally .. ....................... ....................... [ ]Yes [ ]No $________________
2. Work for someone who pays him or her cash .................. ....................... [ ]Yes [ ]No $________________
3. Expect a leave of absence from work due to lay off ........ ....................... [ ]Yes [ ]No $________________
medical, maternity, or military leave.
4. Now receive or expect to receive unemployment benefits .................... [ ]Yes [ ]No $_______________
5. Now receive or expect to receive child support. .............. ....................... [ ]Yes [ ]No $________________
6. Entitled to child support that he/she is not now receiving ....................... [ ]Yes [ ]No $________________
7. Now receive or expect to receive alimony ....................... ....................... [ ]Yes [ ]No $________________
8. Have an entitlement to receive alimony that is not
currently being received ......................... ....................... ....................... [ ]Yes [ ]No $________________
9. Now receive or expect to receive public assistance (TANF) .................... [ ]Yes [ ]No $________________
10. Now receive or expect to receive Social Security or disability ............... [ ]Yes [ ]No $________________
11. Now receive or expect to receive income from a pension/annuity ......... [ ]Yes [ ]No $________________
12. Now receive or expect to receive regular contributions from
organizations or individuals not living in the unit .......... ....................... [ ]Yes [ ]No $________________
13. Receive income/dividends from assets including checking, savings,
certificates of deposit, stocks, bonds, rental property .... ....................... [ ]Yes [ ]No $________________
14. Own real estate or any asset for which you receive income ................... [ ]Yes [ ]No $________________
15. Now receive military pay ........................ ....................... ....................... [ ]Yes [ ]No $________________
16. Now receive workers compensation ........ ....................... ....................... [ ]Yes [ ]No $________________
17. Now receive veterans administration benefits ................. ....................... [ ]Yes [ ]No $________________
18. Do you have income from any source not mentioned above .................. [ ]Yes [ ]No $________________
If yes, please explain: ___________________________________________________________________

Employment:
Applicant:
Circle all applicable: Employed full time Employed part time self – employed
Non-employed Unemployed
Current
Employer___________________________ Position__________________ Date Hired____________
Address_____________________________ Supervisor_________________ Phone________________
Current Wages: $___________________ per: hour week month year (circle one)
Do you expect to earn substantial overtime? () Yes () No If so, how much? ___________________

Co-Applicant:
Circle all applicable: Employed full time Employed part time self – employed
Non-employed Unemployed
Current
Employer___________________________ Position__________________ Date Hired____________
Address_____________________________ Supervisor_________________ Phone________________
Current Wages: $___________________ per: hour week month year (circle one)
Do you expect to earn substantial overtime? () Yes () No If so, how much? ___________________
_____________________________________________________________________________________________

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ASSET INFORMATION
Please answer each of the following questions.
Do any household members have any of the following? If yes, indicate the value.

Checking Account (average 6mon balance) ............... [ ]Yes .. [ ]No $________________

Savings Account ......................................... ............... [ ]Yes .. [ ]No $________________
Certificates of Deposit ................................ ............... [ ]Yes ...[ ]No $________________
Stocks or Bonds .......................................... ............... [ ]Yes .. [ ]No $________________
IRA/s or Retirement Funds ......................... ............... [ ]Yes .. [ ]No $________________
Mutual Funds .............................................. ............... [ ]Yes .. [ ]No $________________
Trust Accounts............................................ ............... [ ]Yes .. [ ]No $________________
Whole or Universal Life Insurance (not Term) .......... [ ]Yes .. [ ]No $________________
Personal Property held as an investment .... ............... [ ]Yes .. [ ]No $________________
Real Estate .................................................. ............... [ ]Yes .. [ ]No $________________
Any Assets not listed above ....................... ............... [ ]Yes .. [ ]No $________________
Have you disposed of any assets in the
previous 24 months for less than fair market value? .. [ ]Yes .. [ ]No

List all information for any asset noted above (including Checking, Savings, IRAs, Keogh accounts, and Certificates
of Deposit) of all household members.

BANK NAME or TYPE OF ACCOUNT BALANCE

INSTITUTION ACCOUNT NUMBER

PREVIOUS RENTAL HISTORY

Name and Address of Your Present Landlord: Do you: □Rent □Own □Other _______________
_____________________________________ Telephone No._________________________________
_____________________________________ How Long Have You Lived There? ________________
_____________________________________ Reason for Leaving. ____________________________
Name and address of your Former Landlord:
_____________________________________ Telephone No._________________________________
_____________________________________ How Long Did You Live There? ________________
_____________________________________ Reason for Leaving. ____________________________

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OTHER INFORMATION:
Driver's License #: __________________________ State: _______________________ Expires: ___________________________

Vehicle Model: ______________________________ Year: _______________ License Plate #:_________________________

HAVE YOU OR ANY HOUSEHOLD MEMBER EVER:

Filed for Bankruptcy? .............................................................................. ........................... ……… [ ] Yes [ ] No
Been evicted from Tenancy? .................................................................... ........................... ……… [ ] Yes [ ] No
Been evicted from Federally Funded Housing for a lease violation including drug use or a crime? [ ] Yes [ ] No
If yes, when: ___________________________________________________
Been convicted of a Felony or Misdemeanor? ......................................... ........................... ……… [ ] Yes [ ] No
If yes, explain: __________________________________________________
Are you or any household member subject to lifetime sex offender registration ................. ………. [ ] Yes [ ] No
Are you or any household member enlisted in the U.S. Military or a veteran ……………………. [ ] Yes [ ] No
Are you or any household member currently receiving housing assistance from HUD or a PHA … [ ] Yes [ ] No
Do you have any special housing needs? ................................................. ........................... ………. [ ] Yes [ ] No
If yes, explain: _____________________________________________________

Emergency Contact:
Nearest Living Relative: _____________________________ __________________________ ____________________________
Name Phone Relationship

Address: ___________________________________________________________________________________________________

MARKETING INFORMATION:
How did you hear about this community? _________________________________________________________________________

I hereby apply to lease the above described premises on substantially the terms set forth herein. As an inducement to Community Housing Partners, Agent
for the owner of the property, to accept this application, I warrant that all statements contained herein are true. I have been advised and understand that
residency at this community entails certain income restrictions and that residency is subject to qualification. I hereby authorize Landlord to procure a
consumer report as defined in the Fair Credit Reporting Act, 15 U.S.C. 1881 a (d) seeking information on the credit worthiness, credit standing, credit
capacity, character, general reputation, personal characteristics, or mode of living. I tender in addition to any security deposit, the amount of $__________
which I acknowledge is the cost of procuring a consumer credit report, employment verification, character references and other administrative set-up costs.
This fee is non-refundable. I agree that in addition to execution of a Lease Agreement that I will execute a tenant certification attesting to the information
contained herein which certification will be made under the penalty of perjury.
A deposit of $________________ is made herein. If the application is approved, said deposit will be held as (partial/full) security for the performance of
the covenants of the lease and as a damage deposit. The full security deposit will be $________________. If the applicant(s) notifies the Landlord within
three (3) days after the execution of this application that applicant(s) no longer wishes to rent said apartment, Landlord agrees to return said deposit in full.
Landlord reserves the right to retain the security deposit if, for any reason, prospective resident withdraws the application for tenancy, if said application is
withdrawn after the time limit set out in the previous sentence. By execution of this application, I hereby authorize Community Housing Partners. to make
such investigations into my credit history as they may deem appropriate. I understand that such investigations typically include (but are not limited to)
verification of employment and salary, rental history and consumer credit reports. By signing below, the applicant gives permission to procure a criminal
background check and understands the results of such background check could affect the approval of this application. The undersigned do hereby
acknowledge disclosure that the licensee, Community Housing Partners represents the Landlord in a real estate transaction.
RESIDENT’S DUTY TO PROVIDE TRUTHFUL & COMPLETE INFORMATION
WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any
matter within the jurisdiction of a federal agency.
Resident acknowledges that federal law and the IRS require Resident to answer all questions about income and student status truthfully and completely at
Resident’s initial certification and at each annual recertification. This information is essential for determining Resident’s eligibility to occupy the Unit.
Resident understands that (s) he must give truthful and complete income and student status information at all times. Resident understands that compliance
with this paragraph is a condition of Resident’s occupancy of the Unit. If Owner discovers, at any time the Lease Term, that Resident purposely gave false
or incomplete income or student status information, Owner may evict Resident from the Unit.
Resident’s Acknowledgement: ___________________
(Initial here)

Applicant: ______________________________________________________________ Date: ____________________

Co-Applicant: ___________________________________________________________ Date: ____________________

Received by: _____________________________________ Date Received: _________________ Time : _____________________

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We are an equal housing opportunity provider. We do not discriminate
on the basis of race, color, sex, national origin, religion, disability or
familial status (having children under age 18), or any other legally
protected characteristic. We do not interfere, threaten, or coerce
persons in the exercise of their fair housing rights. We do not retaliate
against persons who have asserted their rights or persons who have
assisted someone in asserting their rights.