| Landlord Name: __________________________
Mailing Address: __________________________ __________________________ City, State, Zip: __________________________ Phone Number: __________________________ |
Return to:
Phone Number __________________________ Fax Number __________________________ |
I have applied for housing with Hursh & Assoc., Realtors, M. Diann Hursh, broker. This property is owned &/or managed by Hursh Realtors, and a written reference from former landlords is required. Please provide the following information to the above address &/or fax to the number shown within 10 days. Thank you for your cooperation.
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____________________________________ Applicant's name (print) ____________________________________ Soc Sec Number ____________________________________ Applicant's signature |
______________________________________ Prior rental - Street Address _______________________________________ Renter's Name (if different from Applicant) _______________________________________ Date |
STOP - Applicant to go no further - return signed form to agent.
Landlord, Please complete the following information:
Current Landlord ____ or Previous Landlord _______ Dates of Tenancy: from ________ to _________
Amount of monthly rent _______ Their share of rent __________ Utilities included: YES or NO
YES NO 1. Was the rent paid on time? If no, how many times was it late?
YES NO 2. Is there an outstanding balance?
If yes, what is the balance? $__________ Have payment terms been met? __________
YES NO 3. Did the household keep the unit in a clean, safe and sanitary condition.
Including upon move-out? If no, describe unsatisfactory conditions:
YES NO 4. Did the individual/household or their guests alter, damage or vandalize the unit
or common areas or create physical hazards to others or the property?
If yes, describe:
5. Did any member of the household or a guest display any social conduct thata disrupted other residents, staff members or others? If yes, describe:
6. Has this individual/household received any lease violation notices while living at your property? If yes, please explain.
7. Did the individual/household permit persons other than those listed on the lease to live in the unit (other than as a registered guest)?
8. Did the individual/household have a pet? If yes, what kind? _______
If yes, was the pet authorized by the terms of the Lease? YES NO
9. Too your knowledge, did the household ever have their assistance or tenancy terminated for fraud, non payment of rent or failure to cooperate with the recertification process? Was any member of the household asked to vacate an apartment or home? ___ ____
10. To your knowledge is any household member currently facing charges for ... or have they been convicted of a felony, drug related offense, violent act, sexual offense, theft, fraud or are they subject to lifetime registration requirements under a State Sex Offender Registration program? If yes, explain:
11. To your knowledge is any household member currently using, selling, distribution or in possession of an illegal drug or drug paraphernalia?
12. Has any household member given you any false information. If yes, please explain:
13. Would you rent to this individual/household again?
14. Do you recommend this individual/household to us as a future resident?
Overall How would you rate this individual/household? Excellent Good Fair Poor
Other comments
_____________________________________ Phone number ___________________________
Landlord signature & date