pRE-aPPLICATION

/
Head of HouseHold
Name:
Date of birth: / SSN: / Phone:
Current address:
City: / State: / ZIP Code:
Do You: Own/Rent
(Please circle) / Monthly payment: / How long?
iNCOME Information
Current employer/ Income Source:
Phone: / How long?
Position: / Hourly/Salary (Please circle) / Monthly income:
Previous Landlord:
Address: / Phone:
City: / State: / ZIP Code:
BAckground information
Who were you referred by:
Are you currently a student (Y/N)
Have you been a student in the last 12 months (Y/N) / Reason for moving:
Are you currently Homeless (Y/N) / If yes please state where currently staying: / How many times have you been homeless:
Do you claim a Mental Disability
(Y/N) / Do you currently work with someone from Vera French
(Y/N) / If Yes Who:
Other Mental Health Provider:
Please Choose Housing Choices in order to place you on the correct wait list
Supervised Living (Y/N)
If yes do you receive Title 19 (Y/N) / Number of Bedrooms
(circle one)
(1) (2) / Handicap Accessible
(Y/N)
Desired Monthly Rent Payment:
($390.00- $525.00) / Can you get Utilities in your Name (Y/N) / Do you have a current SEC 8 Voucher/ or other subsidy :
(Y/N)
List others who will live with you
Name / Relation / Birthday (mm/dd/yy) / Disability (Y/N)
Release Of Information
I authorize Vera French Housing to verify the information provided on this form as to my employment history, mental health diagnosis, and criminal background check
Signature of applicant / Date
Signature of co-applicant, if for joint account / Date

DAVENPORT POLICE DEPARTMENT LANDLORD BACKGROUND CHECK

Name: ______

Last First Middle Initial

Social Security #:______-______-______D.O.B._____/____/_____

Phone: ______Alternate Phone: ______

Current Address: ______

Street # City State Zip code

Rent: [ ] Own: [ ] Living with Family Member: [ ]

If Renting, Name of Current Landlord: ______Phone: ______

List all aliases: ______

List any co-applicants: ______

List any children who will be living in the household.

Child 1: ______Child 2: ______Child 3: ______

D.O.B.: ______D.O.B.: ______D.O.B.: ______

Child 4: ______Child 5: ______Child 6: ______

D.O.B.: ______D.O.B.: ______D.O.B.: ______

Current Employer: ______

Address: ______Phone: ______

Street # City State Zip code

Please list any additional information you feel is relevant: ______

______

I authorize the release and verification of all information needed to complete a full background

report including criminal and consumer credit report.

______

Applicant (Print Name) Date

Applicant (Signature) Date.

NOTE: ***All fields must be completed in full or request will not be processed.***

This information is being provided at the request of Landlord and Landlord agrees that the decision to rent

is the Landlord’s SOLE decision. The city of Davenport is not an agent of Landlord nor does it guarantee or

warrant the character or suitability of a tenant. The city is simply providing information requested.

______

Property Agent Date

Vera French Housing______

Name of Property

______

Property Address

563-445-7977______563-445-4349

Phone Fax

Please return to the Crime Prevention Unit, Davenport Police Department Fax# 563-888-2081.Fax

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