(SUBJECT TO LANDLORD'S APPROVAL)
SEPARATE APPLICATION REQUIRED FROM EACH APPLICANT OVER AGE 18.
THIS SECTION TO BE COMPLETED BY LANDLORD Address of Property to Be Rented:
Unit __, _____________________, City. STATE. Zip Code Rental Term: __ month-to-month
__ lease from __ to __
Amounts Due Before Occupancy: _____________________________
First Month ______________ Last Month _______________ Security Deposit ___________________________________
THIS SECTION TO BE COMPLETED BY APPLICANT
Full Name (include all names used): _________________ Date of Birth ____/____/_____
Home Phone: ( }_____________ Work Phone: ( ) _____________
Social Security Number: _________________
Driver's License and State: __________________
Vehicle Make: _____________ Model: _________________ Year:____________________
License Plate Number & State: ____________________________
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
Lead Warning Statement
Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, lessors must disclose the presence of known lead-based paint and/or lead-based paint hazards in the dwelling. Lessees must also receive a federally approved pamphlet on lead poisoning prevention.
Presence of lead-based paint and/or lead-based paint hazards (check (i)or(iil below):
(I) Known lead-based paint and/or lead-based paint hazards are present in the housing (explain).
(II) Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.
Records and reports available to the lessor (check (i) or (ii) below):
(II) Lessor has provided the lessee with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list documents below)
(IV) Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.
Lessee's Acknowledgment (initial)
______________ Lessee has received copies of all information listed above.
______________ Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent's Acknowledgment (initial)
_________________ Agent has informed the lessor of the lessor's obligations under 42
U.S.C. 4852ld) and is aware of his/her responsibility to ensure compliance.
Certification of Accuracy
The following parties have reviewed the information above and certify, to the best of their knowledge, that the information they have provided is true and accurate.
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