Rental Application Form Page 3

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16. Monthly payments (automobiles, student loans, child support, alimony, tax judgements, garnishments, etc.)
To ________________________________________________ Amount $ _________________ Balance $ _____________
To ________________________________________________ Amount $ _________________ Balance $ _____________
To ________________________________________________ Amount $ _________________ Balance $ _____________
To ________________________________________________ Amount $ _________________ Balance $ _____________
17. Credit references (credit cards, utilities, or other)
Name ___________________________ Name _____________________________ Name ____________________________
18. Bank references (checking accounts, savings accounts, retirement accounts, etc.)
Name ___________________________
Balance __________________________
Name ___________________________
Balance __________________________
Name ___________________________
Balance __________________________
19. Personal references
Name __________________________________________
Name _______________________________________________
Address ________________________________________
Address _____________________________________________
Address ________________________________________
Address _____________________________________________
Phone #/Email _________________________________________ Phone #/Email ________________________________________
20. Emergency contact information
Name ___________________________________________ Relationship _______________________
Home phone # _____________________ Cell/Work phone # ____________________________ Email ________________________
Address ____________________________________ City ____________________ State ________ ZIP ___________________
21. a. Has Applicant ever filed for bankruptcy?
Yes __________ No _________
If Yes, date filed ___________ Date discharged ____________ State ___________
b. Has Applicant ever been evicted or had a judgment(s) issued against him or her?
Yes __________ No _________
c. Has Applicant ever had property foreclosed upon or given title or deed in lieu of foreclosure? Yes __________ No _________
d. Has Applicant ever had a collection or charged off bad debt?
Yes __________ No _________
e. Is Applicant party to a lawsuit?
Yes __________ No _________
f. Has Applicant ever been convicted of a crime (misdemeanor or felony)?
Yes __________ No _________
If Yes, please explain _____________________________________________________________________________________
22. a. If Applicant is paid on an hourly or weekly basis: Please attach Form W-2 for the past two years
b. If Applicant is self-employed: Please attach U.S. Tax Form 1040 with Schedule C for the past two years
c. If Applicant is military: Please attach copy of orders and LES
Placement agent: Please leave contact information or attach card here:
Agents Name: _____________________________________ Phone #: ___________________________________
Company: ________________________________________ Email: ____________________________________
Address: ____________________________________________________________________________________
I/We hereby certify that the above information is true to the best of my knowledge. I/We hereby authorize the person or firm
to
whom this application is made, and any credit bureau or other investigator agency employed by such person, to investigate the
references herein listed and any statements or other data obtained from me or any other person pertaining to my credit or
financial responsibility. I/We also acknowledge receipt of a copy of this application.
_____________________________________ _____/_____/_____ _____________________________________ _____/_____/_____
Applicant’s signature
Date
Applicant’s signature
Date
_____________________________________
_____________________________________
Print name
Print name
3

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