Sample Rental Application Form Page 3
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3HOUSEHOLD COMPOSITION List the head of your household and all members who live in your home.
Give the relationship of each family member to the head.
BIRTHDATE
SOCIAL
MEMBER NO.
FULL NAME
RELATIONSHIP
M/D/Y
SECURITY NO.
Head of Household
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Are there any special housing needs or reasonable accommodations that the household will require?
The information provided above is true and complete to the best of my/our knowledge and belief. I/we consent to
the disclosure of income and financial information from my/our employer and financial references for purposes of
income and asset verification related to my/our application for tenancy.
Applicant
Date
Co-Applicant
Date
A p p l i c a b l e t o p r o p e r t i e s l o c a t e d i n a n o n p a r t i c i p a t i n g j u r i s d i c t i o n r e c e i v i n g f e d e r a l
In accordance with the data collection information required by the
h o m e f u n d s f r o m PH FA .
Department of Housing and Urban Development (HUD), please provide the following information for the
head of household.
RACE
White
American Indian/Alaska Native & White
Black or African American
Asian & White
Asian
Black/African American & White
American Indian or Alaska Native
American Indian/Alaska Native & Black/African
American
Native Hawaiian or Other Pacific Islander
Other Multi-racial
ETHNICITY
GENDER
Hispanic or Latino
Male
Not Hispanic or Latino
Female
January 2003- DF
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