RECEIVED FROM ___________________________________________, Applicant,

the sum of _________________________________________________ ($ ________)

for the purpose of verifying information submitted on the application and for holding the rental dwelling commonly known as _________________________________________

________________________________________________________________ (Address)

until __________________ (Date) or such earlier time as the undersigned owner/manager is able to complete a verification of the information submitted to on the Applicant's rental application.

This dwelling will be rented to the Applicant provided that

1) the applicant's rental application and credit history satisfy the owner;

2) within 24 hours of being approved, the Applicant signs the rental agreement

offered by the Owner/Manager, a copy of which the Applicant has received, read and approved; and

3) within 24 hours of being approved, the Applicant pays all the sums necessary to move in.

Should the applicant be approved to rent this dwelling and meet all three of the conditions above, this entire deposit will be refunded except for the sum of _____________________ (Amount), which shall be used to pay for verification of the Applicant's rental application.

Should the Applicant be approved to rent this dwelling and not do so, none of this deposit will be refunded.

Should the Applicant not be approved to rent this dwelling, the Owner/Manager will refund all of this deposit except for the sum __________________ (Amount), which shall be used to pay for verification of the Applicant's rental application.

Date: _____________________ Time: _____________________

Applicant: ____________________ Applicant: ____________________

Date: _____________________ Time: _____________________

Owner/Manager: ___________________________________