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Note: All fields are required. Use “N/A” where necessary.

Before your application is processed, you must pay the $50 application fee here

Applicant
Last Name	First Name	Middle Initial
Current Address
City	State	Zip Code
Home Phone	Work Phone
Social Security #	Date of Birth	Email
Marital Status Single Married Divorced Separated Widow

Co-Applicant
Last Name	First Name	Middle Initial
Current Address
City	State	Zip Code
Home Phone	Work Phone
Social Security #	Date of Birth	Email
Marital Status Single Married Divorced Separated Widow

Household Composition

List the Head of Household and all other members who will be living in the unit. Give the relationship of each person to the Head of Household

Number of people in household

Name	Relationship	Birth Date	Age	Sex	Social Security	Full Time Student? Y/N

Do you expect a change in your household composition within the next 12 months? Yes No
If yes, please explain:

Income Information
Please answer each of the following questions. For each "yes", provide details below. Does any member of your household:
1. Work full time, part time, or seasonally	Yes No	$
2. Expect to work for any period during the year	Yes No	$
3. Work for someone who pays him or her cash	Yes No	$
4. Expect a leave of absence from work due to lay off, medical, maternity, or military leave	Yes No	$
5. Now receive or expect to receive unemployment benefits	Yes No	$
6. Now receive or expect to receive child support	Yes No	$
7. Entitled to child support that he/she is now receiving	Yes No	$
8. Now receive or expect to receive alimony	Yes No	$
9. Have an entitlement to receive alimony that is not currently being received	Yes No	$
10. Now receive or expect to receive public assistance (TANF)	Yes No	$
11. Now receive or expect to receive Social Security or disability	Yes No	$
12. Now receive or expect to receive income from a pension/annuity	Yes No	$
13. Now receive or expect to receive regular contributions from organizations or individuals not living in the unit.	Yes No	$
14. Receive income/dividends from assets including checking, savings, certificates of deposit, stocks, bonds, rental property	Yes No	$
15. Own real estate or any asset for which you receive no income	Yes No	$
16. Now receive military pay	Yes No	$
17. Now receive self employment income	Yes No	$
18. Now receive workers compensation	Yes No	$
19. Now receive veterans administration benefits	Yes No	$
20. Do you have income from any source not mentioned above	Yes No	$
If yes, please explain

Employment

Asset Information
Please answer each of the following questions. Do any household members have any of the following? If yes, indicate the value
Checking Account (average 6 mo. balance)	Yes No	$
Savings Account	Yes No	$
Certificates of Deposit	Yes No	$
Stocks or Bonds	Yes No	$
IRA/s or Retirement Funds	Yes No	$
Mutual Funds	Yes No	$
Trust Accounts	Yes No	$
Whole or Universal Life Insurance (not Term)	Yes No	$
Personal Property held as an investment	Yes No	$
Real Estate	Yes No	$
Any Assets not listed above	Yes No	$
Have you disposed of any assets in the previous 24 months for less than fair market value?	Yes No
If yes please explain

List all information for any asset noted above (including Checking, Savings, IRAs, Keogh accounts, and Certificates of Deposit) of all household members.

Bank Name or Institution	Type of Account	Account Number	Balance

Rental History

Present Landlord	Landlord's no.
Landlord's Address	How long have you lived there?
Current Rent Amount	Reason for Leaving

If less than one year at previous address:
Former Landlord	Former Landlord's no.
Former Landlord's Address	How long did you lived there?
Former Rent Amount	Reason for Leaving

Other Information
Driver's License #	State	Expires
Vehicle Model	Year	Licence Plate #
Have you ever been evicted and/or owe any Property Management Company or Private Owner money? Yes No
If yes, please explain
Have you ever been convicted of a Felony? Yes No
If yes, please explain
Emergency Contact
Nearest Living Relative
Name	Phone	Relationship
Address

I hereby apply to lease the above described premises on substantially the terms set forth herein. As an inducement to Fountainhead Services , Agent for the owner of the property, to accept this application, I warrant that all statements contained herein are true. I have been advised and understand that residency at this community entails certain income restrictions and that residency is subject to qualification. I hereby authorize Landlord to procure a consumer as defined in the Fair Credit Reporting Act, 15 U.S.C. 1881 a (d) seeking information on the credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I agree that in addition to execution of a Lease Agreement that I will execute a tenant certification attesting to the information contained herein which certification will be made under the penalty of perjury.

A deposit of $________________ is made herein. If the application is approved, said deposit will be held as (partial/full) security for the performance of the covenants of the lease and as a damage deposit. The full security deposit will be $________________. If the applicant(s) notifies the Landlord within three (3) days after the execution of this application that applicant(s) no longer wishes to rent said apartment, Landlord agrees to return said deposit in full. Landlord reserves the right to retain the security deposit if, for any reason, prospective resident withdraws the application for tenancy, if said application is withdrawn after the time limit set out in the previous sentence.

By execution of this application, I hereby authorize Fountainhead Real Estate Services LLC to make such investigations into my credit history as they may deem appropriate. I understand that such investigations typically include (but are not limited to) verification of employment and salary, rental history and consumer credit reports. By signing below, the applicant gives permission to procure a criminal background check and understands the results of such background check could affect the approval of this application. The undersigned do hereby acknowledge disclosure that the licensee, Fountainhead Real Estate Services LLC represents the Landlord in a real estate transaction.

RESIDENT'S DUTY TO PROVIDE TRUTHFUL & COMPLETE INFORMATION
WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any matter within the jurisdiction of a federal agency.

Resident acknowledges that federal law, VHDA and IRS requires Residents to answer all questions about income and student status truthfully and completely at Resident's initial certification and at each annual recertification. This information is essential for determining Resident's eligibility to occupy the Unit.

Resident understands that (s) he must give truthful and complete income and student status information at all times.

Resident understands that compliance with this paragraph is a condition of Resident's occupancy of the Unit. If Owner discovers, at any time the Lease Term, that Resident purposely gave false or incomplete income or student status information, Owner may evict Resident from the Unit.

Please enter the text above

Applicant
Check all applicable: Employed Full Time Employed Part Time Self-Employed Non-Employed Unemployed
Current Employer	Position	Date Hired
Employer Address	Supervisor	Phone
Current Wages $	Per Hour Week Month Year
Do you expect to earn substantial overtime? Yes No
If yes, how much?

Co-Applicant
Check all applicable: Employed Full Time Employed Part Time Self-Employed Non-Employed Unemployed
Current Employer	Position	Date Hired
Employer Address	Supervisor	Phone
Current Wages $	Per Hour Week Month Year
Do you expect to earn substantial overtime? Yes No
If yes, how much?

Applicant

Co-Applicant

Household Composition

Income Information

Employment

Applicant

Co-Applicant

Asset Information

Rental History

If less than one year at previous address:

Other Information