Sample Rental Application Form Page 2
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3ANNUAL INCOME
OTHER
HOUSEHOLD
MEMBERS 18
SOURCE
APPLICANT
CO-APPLICANT
YRS OR OLDER
TOTAL
Gross Salary
Overtime Pay
Commissions/Fees/Tips/
Bonuses
Unemployment Benefits
Workers Compensation,
etc.
Social Security, Pensions,
Retirement Funds, etc.,
Received Periodically
TANF Payments
Alimony, Child Support
Interest and/or Dividends
Net Income from
Business
Net Rental Income
Other:
TOTAL:
INCOME
CASH
FROM
NAME OF FINANCIAL
ACCOUNT
ASSETS
VALUE
ASSETS
INSTITUTION
NUMBER
Checking Account
$
$
Savings
$
$
Certificate of Deposit
$
$
Mutual Funds/Stocks/Bonds
$
$
Real Estate
$
$
Life Insurance
$
$
Other:
$
$
TOTAL:
$
$
I ______ have ______have not disposed of any asset(s) valued at $1,000 or more in the past two years for less
than the fair market value of the item. If yes, please list the asset value under the other column in the
above listing of assets.
Are all household members full-time students?
Yes _____
No _____
2
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Parent category: Business