Fillable Application to Rent (Nine Seventeen Eleventh)

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Application to Rent (Nine Seventeen Eleventh)

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  • 22 check-boxes
  • 182 other fields

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Application to Rent
Form 110 © 2012 Page 1 of 4
The unauthorized copying, duplicating, downloading, display or any other use of this form is not permitted.
This form does not constitute legal advice. For legal advice, please consult your attorney.
For the rental property located at: __________________________________________________________________ (“Premises”).
APPLICANT (Each Applicant over the age of 18 must complete their own application form and be approved for tenancy):
Last Name: First Name: Middle Name:
Cell Phone: Work Phone: Home Phone:
Current Address:
Date of
Birth
Social Security# or ITIN: Driver’s License # / Exp. Date: Other Government Id No.:
Email: Other Names Used In the Last 10 Years:
CURRENT INCOME:
$______________
□Weekly □Monthly □Yearly
Source: Proof of Income:
□ Yes □ No.
$______________
□Weekly □Monthly □Yearly
Source: Proof of Income:
□ Yes □ No.
Other Income Sources:
EMPLOYMENT INFORMATION:
CURRENT EMPLOYMENT
Employer: Address:
Phone: Supervisor’s Name:
Current Title:
Current Pay Rate: $ Per □ Week □Month (Check one)
Employed From: To:
Are you currently employed with the above company?
□ Yes □No
* We will be contacting current employer to verify the accuracy of all
of the above-stated information.
PRIOR EMPLOYMENT
Employer: Address:
Phone: Supervisor’s Name:
Application to Rent
Form 110 © 2012 Page 2 of 4
The unauthorized copying, duplicating, downloading, display or any other use of this form is not permitted.
This form does not constitute legal advice. For legal advice, please consult your attorney.
Title:
Current Pay Rate: $ Per □ Week □Month (Check one)
Employment From: To:
Reason for leaving:
ADDITIONAL OCCUPANTS: (All persons 18 or over must fill-out their own application, unless otherwise allowed by law).
First, Middle, Last Name:
Date of Birth: Relationship To Applicant:
First, Middle, Last Name: Date of Birth: Relationship To Applicant:
First, Middle, Last Name:
Date of Birth: Relationship To Applicant:
RESIDENCE INFORMATION:
CURRENT RESIDENCE
Address: (Street address, City, State & Zip):
Tenancy From: To: Last rent paid: $ /Month
Owner/Manager’s Name: Owner/Manager’s Phone #:
Are you currently residing here? □ Yes □No
Did you ever pay your rent late or fail to pay your rent, while you were
residing here? □ Yes □No
Were you ever given a notice stating that you are violating the rental agreement or rules while you were residing here? □Yes □No
What is your Reason for Leaving?
PREVIOUS RESIDENCE(S)
[Please List for the Last Five (5) Years (Attach Additional Pages If Needed)]
Address (Street address, City, State & Zip):
Dates of Tenancy: From: To: Rent paid at End of Tenancy: $ /Month
Owner/Manager’s Name: Owner/Manager’s Phone #:
Are you currently residing here? □ Yes □No
Did you ever pay your rent late or fail to pay your rent, while you were
residing here?
□ Yes □No
Were you ever given a notice stating that you are violating the rental agreement or rules while you were residing here? □ Yes □No
What was your Reason for Leaving?
PREVIOUS RESIDENCE #2
Address (Street address, City, State & Zip):
Dates of Tenancy: From: To: Rent paid at End of Tenancy: $ /Month
Owner/Manager’s Name: Owner/Manager’s Phone #:
Application to Rent
Form 110 © 2012 Page 3 of 4
The unauthorized copying, duplicating, downloading, display or any other use of this form is not permitted.
This form does not constitute legal advice. For legal advice, please consult your attorney.
Are you currently residing here? □ Yes □No
Did you ever pay your rent late or fail to pay your rent, while you were
residing here? □ Yes □No
Were you ever given a notice stating that you are violating the rental agreement or rules while you were residing here? □ Yes □No
What is your Reason for Leaving?
CREDIT INFORMATION (Please list all your financial obligations and assets):
Bank Account type
(Checking or Savings)
Account Number
Name of Bank Branch or Address of
Bank
Balance
1. $
2. $
3. $
Credit Accounts
(Name of Creditor)
Account Number
Address Phone Number Monthly Payment
1. $ /Mo.
2. $ /Mo.
3. $ /Mo.
Other Obligations: Monthly Amount Owed:
Lienholder/Bank:
Creditor’s Phone # Total Amount Owed:
1. Car Payment $ /Mo. $
2. Child Support $ /Mo. $
3. Alimony $ /Mo. $
4. Other: $ /Mo. $
VEHICLE INFORMATION:
I will have ______ (insert number) vehicles parked at the Premises. Description of Automobiles of Applicant:
1. Make: Model: Year: License No.: Color:
2. Make: Model: Year: License No.: Color:
Other Vehicles (motorcycle, etc). Please describe:___________________________________________________
1. Make: Model: Year: License No.: Color:
PERSONAL REFERENCES:
Name: Address Phone Number Relationship
1.
2.
Application to Rent
Form 110 © 2012 Page 4 of 4
The unauthorized copying, duplicating, downloading, display or any other use of this form is not permitted.
This form does not constitute legal advice. For legal advice, please consult your attorney.
3.
PET INFORMATION:
Name: Type/Breed: Height/Weight: License No.:
EMERGENCY CONTACT INFORMATION (In case of Emergency, notify:)
Name: Address Phone Number Relationship
1.
2.
GENERAL INFORMATION: (Check the box next to the answer that applies)
Do you smoke?
□ YES □ NO
Have you ever been a party to a lawsuit? (If so, describe below)
□ YES □ NO
Have you ever filed for bankruptcy? (If so, describe below)
□ YES □ NO
Do you have any liquid-filled furniture or do you intend to use
□ YES □ NO
liquid-filled furniture in the Premises? (If so, describe below)
Have you ever been convicted for a crime against persons or property?
□ YES □ NO
Have you ever been evicted for non-payment of rent or any other
□ YES □ NO
reason or asked to leave a prior residence?
If you answered “YES” to any of the above questions, please explain below (Use additional pages and attach if necessary):
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
CREDIT CHECK/SCREENING FEE RECEIPT: Owner/Agent received the amount of $______________ (“Application Screening
Fee”), which will be used to cover the cost of obtaining information about Applicant; including the cost of obtaining personal reference
checks, consumer credit reports, criminal background checks and other similar information, such as tenant screening service reports
regarding past unlawful detainer litigation. This Application Screening Fee includes the following costs:
1. Cost to purchase personal reference checks, consumer credit reports and/or
other tenant screening service reports regarding prior unlawful detainer actions: $______________
2. Processing costs (including the reasonable value of time spent by
Owner/Agent and/or his agent in obtaining, reviewing & verifying the
information obtained): $______________
Applicant represents that all information given and statements made on this application are true and correct. Applicant hereby
authorizes Owner/Agent to verify and investigate by whatever means possible all facts and references stated herein, including but
not limited to, current and previous landlords and employers, and personal references. Applicant hereby authorizes Owner/Agent
to obtain Unlawful Detainer, Credit Reports, Telechecks, and/or criminal background reports. Applicant agrees to furnish
additional credit and/or personal references upon request. Applicant understands that incomplete or incorrect information
provided in the application may cause a delay in processing and/or may result in denial of tenancy. Applicant acknowledges that
Owner/Agent will rely on the information provided herein, and that any material misstatement(s) will, at Owner/Agent’s option,
be a material and non-curable breach of any subsequent rental agreement and grounds for immediate eviction.
Signature of Applicant: _______________________________________ Date: ___________________________
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Application to Rent (Nine Seventeen Eleventh)

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Completed 23 May 2021

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