Application To Rent Form Page 4
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6Please Type or Print Neatly in Blue or Black Ink
Each Proposed Tenant Must Fill Out a Separate Application
PERSONAL FINANCES
NAME OF BANK
BANK ADDRESS
ACCOUNT
Checking:
Savings:
Please include last 6 months of statements
PERSONAL PROPERTY
Do you own furniture? Yes No
Own a car? Yes No If Yes, provide: _________________________ ____________________
Make/Model/Year
License #
OTHER ASSETS
List and describe any other assets such as real property, personal property, stocks, bonds, etc.
Asset type
Description
FINANCIAL OBLIGATIONS
____________________ ______________________________ _____________ _________________
Payment to
Address
Account #
Amount/Period
____________________ ______________________________ _____________ _________________
Payment to
Address
Account #
Amount/Period
ELIGIBILITY INFORMATION
Do you have a diagnosed mental illness? Yes No If yes, describe: (DSM-5 diagnosis and
Medications): ________________________________________________________________________
Psychiatrist’s name, address, and telephone number: ________________________________________
Are you a Santa Barbara County Alcohol, Drug and Mental Health Services client? No Yes
Who is your case manager? Name
Phone # _______________
Date of Last Physical Examination: ____________ Are you being treated for any medical condition
or illness? Yes No If yes, please describe: ____________________________________________
Medical doctor’s name, address and telephone number: _____________________________________
Will you sign an authorization for release of information concerning your disability? Yes No
Are you a veteran or a spouse of a Veteran? Yes No
Do you smoke? Yes No
Are you currently receiving any housing assistance or rental subsidy? Yes No
Do you have any pets? Yes No
Have you ever: been evicted? Yes No If yes, please explain: _____________________________
_____________________________________________________________________________________
Are you a registered sex offender or subject to a lifetime registration requirement? Yes No
Hollister Apartments Rental Application, rev. 1/2016
Application Page 2 of 4
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