Effective: 10/01/16 MRC APP.2
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AUTHORIZATION TO RELEASE INFORMATION
PROPERTY NAME & NUMBER:
ADDRESS: CITY/STATE: _________________
APPLICANT INFORMATION: (Separate form to be completed by each household member over the age of 18)
FULL NAME: ____________________________________________________________________
CURRENT ADDRESS: CITY/STATE: ________________
PREVIOUS ADDRESS: CITY/STATE: _________________
SOCIAL SECURITY NUMBER: DATE OF BIRTH: ______________
DRIVERS LICENSE & STATE: _______________________________________________________
HEIGHT: WEIGHT: RACE: SEX:
I hereby authorize any investigator, Site Manager, or other authorized representative, for the purpose of
determining eligibility for occupancy at Apartments, bearing this
release, or a copy thereof, to obtain any information in your files pertaining to my employment,
unemployment, income from benefits such as Social Security supplement (SSI), Veterans Administration
(VA checks), Department of Convictions, Civil or Traffic Records, including, but not limited to, Academic
Achievement, Attendance, Athletic, Personal History, and Disciplinary Records, Medical Records, and
Credit Records.
Apartments has my permission to verify all information listed on this
application with the following persons/agencies of the Human Resources Department: A.D.C./C. Support,
Social Security Administration, Credit Bureau, Private/City/County Schools, Federal/State Tax Division,
Workman’s Compensation Agencies, Sheriff’s Department, Current/Past Landlords, Current/Past
Employers, Veterans Administration, Unemployment Agency, Child Support Division, Police Department,
Narcotics Division, Banking Institution, Credit Unions, and Utility Companies.
I hereby direct you to release such information upon request of bearer. This release is executed with full
knowledge and understanding that the information is for official and confidential use. Consent is granted,
to furnish such information, as described above, to third parties in the course of fulfilling its official
responsibilities. I hereby release you from any and all liability for damages of whatever kind, which may at
any time result to me, my heirs, family, or associates because of compliance with this authorization and
request to release information, or any attempt to comply with it.
This release is valid as long as I am a tenant of the above apartments.
Photo copies of this authorization shall be deemed as valid as the original.
Signed this day of , 20 .
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Site Manager’s Signature Applicant’s Signature
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