RECEIVED FROM, ___________________________________________, Applicant, the sum of _____________________________________________ $ _____________

for the purpose of verifying the information submitted on the application to rent that dwelling commonly known as _____________________________________________.

It is understood that this sum received is in no way to be considered a deposit to hold the dwelling. The Owner/Manager may take other applications to rent this dwelling and

indeed may have already done so.

The sum received is refundable only if the Owner/Manager selects another applicant to rent the dwelling BEFORE checking the Applicant's credit history. Otherwise, this sum is entirely nonrefundable.

Date: ____________________ _______________________________________

Owner/Manager

Time: ____________________

_______________________________________

Applicant

_______________________________________

Applicant