Pre-Application Form (Page 4 of 4) in pdf

Landlord References. Please complete the following information for all locations you have lived in for the past three (3) years.

Current Address Information

Current street address, city, State, Zip: ___________________________________________________________________________

Lived there from: ________________

to _________________

# of bedrooms: __________________

Rent $______________

Reason for moving: ___________________________________________________________________________________________

Current Landlord’s name and phone #: ___________________________________________________________________________

Previous Landlord Information

Street address, City, State, Zip Code: _____________________________________________________________________________

Lived there from: ________________

to _________________

# of bedrooms: __________________

Rent $______________

Reason for moving: ___________________________________________________________________________________________

Previous Landlord’s name and phone #: ___________________________________________________________________________

Street address, City, State, Zip Code: _____________________________________________________________________________

Lived there from: ________________

to _________________

# of bedrooms: __________________

Rent $______________

Reason for moving: ___________________________________________________________________________________________

Previous Landlord’s name and phone #: ___________________________________________________________________________

PHA will be contacting all former landlords for the period three years (3) from the date of application.

WARNING: Title 18 U.S.C. 1001 provides in part that whoever knowingly and willfully makes or uses any document containing any

false, fictitious or fraudulent statement or entry in any matter in jurisdiction or any department or agency of the United States shall be

fined not more than $10,000 or imprisoned for not more than five (5) years, or both.

PLEASE NOTE: You are required to notify the Housing Authority (in writing) of any change of address. If we cannot contact you at

the listed address, your name will be removed from the waiting list.

I certify that the information given is accurate and complete and understand any misrepresentation will disqualify the application. I

authorize the owner to obtain a credit report(s) verify or check any of the information given including credit references, employment,

and income and contact any previous landlords. By signing this form, I certify the information to be true and correct. Applications

cannot be processed without signature.

________________________________

___________

____________________________

_________

Signature of the Head of household

Date

Co-Applicant’s Signature

Date

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Pre-Application Form Page 4