Preliminary Application Form - Housing And Redevelopment Authority Of Winona, Mn Page 2

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Winona Housing and Redevelopment Authority
1756 Kraemer Drive, Suite 100
Winona, MN 55987
(507)454-3665
~ HRA Police Record Verification ~
State of
County of
Dear Applicant:
The Winona HRA tenant selection policy obliges us to verify certain information about all
members of families living in or applying for admission to our developments. Specifically,
the HRA wishes to avoid admitting a family, any one of whose members is involved in
criminal activity, which would adversely affect the health, safety or welfare of other tenants.
To comply with this requirement, we ask your cooperation in supplying information to the
Winona HRA to complete a criminal background check on each adult in the household.
Please list the following for all adult members
(18 & Older) of the household.
Full Name
First
Middle
Last
D.O.B.
SSN
Driver License #
First
Middle
Last
D.O.B.
SSN
Driver License #
First
Middle
Last
D.O.B.
SSN
Driver License #
First
Middle
Last
D.O.B.
SSN
Driver License #
Applicant's Release
I hereby authorize the release of the information requested above. I hereby give my
permission to the Winona HRA to receive information on any arrests, convictions or criminal
history background from local police and sheriff departments, and the national criminal
history record repository.
Signature
Date
Signature
Date
Signature
Date
Signature
Date

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