Fair Housing Application Form

FAIR HOUSING APPLICATION FORM

Property and Unit

Property Address:

Desired Move-In Date:   Lease Term Requested (months):

Applicant Information

Co-Applicant / Other Occupants

Employment and Income

Rental History

Background and Screening

Have you ever been evicted or had a lease terminated? Yes No

Have you ever been convicted of a felony or misdemeanor other than minor traffic offenses? Yes No

Applicant consents to landlord/agent obtaining consumer reports, credit reports, employment and rental verifications for screening purposes. Applicant authorizes release of such information and releases those providing such information from liability. Applicant understands that false statements or omissions are grounds for denial or later termination of tenancy.

Fees and Payment

Application Fee Amount: $   Payment Method:

Acknowledgement: I acknowledge that the application fee is non-refundable unless required otherwise by law.

Health, Pets and Vehicles

Pets: Yes No

Lead-Based Paint and Disclosures

Is the property known to have been built before 1978? Yes No Unknown

If the property is pre-1978, the landlord will provide the federally required disclosure and any available records or reports related to lead-based paint. Applicant acknowledges receipt or waiver of such materials as applicable.

Reasonable Accommodation

Applicant requests a reasonable accommodation for a disability? Yes No

Disclosures and Acknowledgements

Equal Housing Opportunity: Applicant acknowledges that the landlord/agent adheres to federal and state fair housing laws prohibiting discrimination on the basis of race, color, religion, sex, national origin, familial status, disability, and other protected classes. Any determination on this application will be made in compliance with applicable fair housing laws.

Authorization and Certification: Applicant certifies that all information provided in this application is true, complete and correct. Applicant authorizes verification of any information provided, including but not limited to credit reports, employment verification, rental history, criminal records, and public records. Applicant understands that providing false or misleading information is grounds for denial of the application or for subsequent termination of tenancy.

Release: By signing below, Applicant releases and holds harmless any person, employer, or institution that provides information to the landlord/agent in response to verification inquiries in good faith.

Optional Demographic Information (For monitoring only)

Submission of the following demographic information is voluntary and will not affect application outcome. Check all that apply:

Race/Ethnicity: White Black or African American Asian American Indian or Alaska Native Other

Emergency Contact

Additional Information

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