Rental Application Template

Information You May Be Asked To Provide

The vital stats will be required for EVERY PERSON IN THE HOUSEHOLD!

First listing should be the “head of house.”   or “Self” if single occupant.

Address Line 2:
Phone: (home and/or cell, 1 # required):
Birth Date:
Social Security Number:
CA ID or Drivers License Number:

Medical Record Numbers that are NOT Medi-Cal or -Care:

Bank Name:
Bank Address:

Bank Name:
Bank Address:

(Add more items as needed. All accounts for all household members must be listed.)


Looking for (Size of unit):


Annual: $
Monthly: $
(Repeat for as many sources of income as apply for all household members.)

Total per person/month:
Total per person/year:
Total for household/month:
Total for household/year:
Credit score # for all in household:


Does anyone live with you now who is not listed above: If yes, please explain:

Do you expect a change in your household composition? If yes, please explain:

Are you living in a subsidized unit? If so, what subsidy?

Do you have a Section 8 or Housing Choice Voucher? (Not same as question above.)

Are you (or anyone in your household) or do you (or they) have (mark all that apply):  (The items marked with a + may help you get housing.  Those marked with a – will probably make it harder.)

*+ A Disability (psychiatric)? Diagnoses?
*+ A disability (physical): (Broad details helpful)
*+ Over the age of 55?
*+ Over the age of 62?
*+ HIV Positive?
*+ Veteran?

Any prior evictions (If yes, give short details)

Any unlawful detainers? (If yes, give short details)

*+ Hispanic?
*+ A student?

(Some properties give preference if attending school nearby.)

*+ Recovering from drug/alcohol addiction?
*- Pet(s)? (check property requirements and deposits)
* A service/companion animal? (Deposits may still be required, but NO DENIALS ALLOWED!)
* A live-in care attendant? (This may change unit size)

* Smoke?
* Medi-Care?
* Medi-Cal?


Current Employment: (list all in household)

Name of business:
Name of Supervisor:
Length of time worked there:

(Some properties give preference to those who work/live in their city.)

Assets: (other than checking/savings accounts. List all for all household members.)

Joint accounts if any (Same as above.)
Life insurance (List any/all):
Do you (or anyone in household pay for child care? If so, please list vital statistics for child(ren) and info.
Do you have custody of child(ren)? (Same as above.)
Do you (or anyone in household) have a car?
If so, Make, Model, License & Reg. #:
Are you (or anyone in household) a convicted sex offender who must register?
Any other felony convictions?

Are you and all in your household a U.S. citizen or legal immigrant? (Sign proper application forms and check proper boxes.)


Details of modifications needed in unit and on property:

What medical insurance premiums do you (and/or household) pay and how much ($ monthly? $ yearly?):

What medical expenses do you (and/or household) expect to incur and how much ($ monthly? $ yearly?) List all. OTC included, but receipts/proof may be needed.:


Info for disability verification: (friendly agency)

Title (if applicable):
Name of Org:


Info for medical verification if required: (doctor, same info as above)


PREVIOUS RENTAL HISTORY (as far back as you can go.):

Name and address of your present landlord:
Name of Complex:
How long did you live here?
Reason for leaving?
Total Rent is $
My portion of the rent is $

(Same info for as many as far back as possible)

Previous Address:
Name and address of your former landlord:
How long did you live here?
Reason for leaving?
Total Rent was $
My portion of the rent was $


List all states where you and all members of your household have resided.


Generated by Sheela Gunn-Cushman

This entry was posted in Housing, resources, Sheela Gunn Cushman and tagged . Bookmark the permalink.

Comments are closed.