Fillable Duke Barrington Rental Application (Page 4 of 5) in pdf

Duke Barrington Rental Application Page 4

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Yes

COMPLETE EACH ITEM:

I receive periodic payments from insurance policies, if yes, how many policies? ______

I receive long term care insurance payments that exceed $180/day or $67,000 annually.

I receive other recurring or periodic income not listed above. Describe_______________

CHILD SUPPORT

I receive child support. If yes, from how many parents do you receive support?

If yes, is child support

paid directly to FIA? (Circle One)

Yes

I have been awarded a judgment for child support but have not been receiving payments.

I anticipate filing a claim for child support within the next twelve months.

ASSETS

(Include all assets held or owned either in or outside of the United States)

I have a savings account(s) at: __________________________ (List name(s) of institution)

I have a checking account(s) at: _________________________ (List name(s) of institution)

I have certificates of deposit at: _________________________ (List name(s) of institution)

I have cash held in my home or in a safety deposit box.

I have savings bonds. If yes, how many? ______

I have Treasury Bills. If yes, how many? ______

I have stocks.

I have bonds

I have mutual funds.

I have IRA's or Keogh account(s) at: _____________________ (List name(s) of institution)

I have time certificate(s) at: ____________________________ (List name(s) of institution)

I own real estate. If yes, how many properties? ______

I own a mobile home.

I have land contracts. If yes, how many? ______

I hold a mortgage or deed of trust.

I have revocable trusts. If yes, how many trusts? ______

I have whole life or universal life insurance policy/policies. If yes, how many policies? ______

I have personal property held for investment purposes (gems, jewelry, collections, etc.).

I have lump sum receipts or one-time receipts.

I have another name(s) listed on one or more of the above assets for beneficiary or other purposes, such

as, power of attorney. These other persons do not own the assets and receive no income from the

assets.

I have joint ownership on one or more of the above assets.

REV6/24/2014

Duke Barrington Rental Application Page 4

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