Reference Sheet

Reference Sheet
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Prospective Tenant Form Due Date

MonthDayYear
Date
APPLICANT INFORMATION
Full Name:*

First NameLast Name
Do you have a middle name?*

YesNo
Middle Name:*
Middle Name
Social Security Number:*
Birth Date:*
Marital Status:*

SingleMarriedDivorced
Gender:*

MaleFemale
Do you have a cell phone?*

YesNo
Cell Phone Number:*
Please enter a valid phone number.
Do you have a home phone (landline)?*

YesNo
Home Phone Number:*
Please enter a valid phone number.
Do you have an email address?*

YesNo
Email Address:*
example@example.com
Are you employed?*

YesNo
Employer Zip Code:*
GROSS Monthly Household Income:*
Driver's License Number:*
Example: A123-456-789-123
State of Driver's License:*
Enter abbreviation. Example: MN, ND, SD, NY, etc.
EVICTION DISCLOSURE
Has the applicant ever been evicted?*

YesNo
CO-APPLICANT INFORMATION
Did you have a co-applicant on your applicant? (Spouse, Significant Other, Another Adult Household Member)*

YesNo
Full Name:*

First NameLast Name
Does the Co-Applicant have a middle name?*

YesNo
Co-Applicant's Middle Name:*
Middle Name
Co-Applicant's Social Security Number:*
Co-Applicant's Birth Date:*
Does the Co-Applicant have a cell phone?*

YesNo
Co-Applicant's Cell Phone Number:*
Please enter a valid phone number.
Does the Co-Applicant have a home phone (landline)?*

YesNo
Co-Applicant's Home Phone Number:*
Please enter a valid phone number.
Does the Co-Applicant have an email address?*

YesNo
Co-Applicant's Email Address:*
example@example.com
PROFESSIONAL REFERENCES

NOTE: DO NOT list friends, relatives, or personal advocates. Professional references include, but not limited to teachers, bankers, co-workers, employers, social workers, pastors, etc.
- YOU MUST PROVIDE THREE PROFESSIONAL REFERENCES. Family members and friends are not professional references.
  - Examples of professional references include, but are not limited to: Supervisors, current/former coworkers, professors, advisors, etc.
YOU MUST PROVIDE A FAX NUMBER AND/OR EMAIL ADDRESS FOR EACH REFERENCE. If you do not list a fax number or email address for all references, you will no longer be considered for the housing that is available.
Reference #1
Name:*
Relationship to Applicant:*
Phone Number:*
Please enter a valid phone number.
YOU MUST PROVIDE A FAX NUMBER AND/OR EMAIL ADDRESS FOR EACH REFERENCE. If you do not know the fax number or email address, please get this information before completing the form.

If you do not list a fax number or email address for all references, you will no longer be considered for the housing that is available.
Fax Number:
Please enter a valid phone number.
Email Address:*
example@example.com
Reference #2
Name:*
Relationship to Applicant:*
Phone Number:*
Please enter a valid phone number.
YOU MUST PROVIDE A FAX NUMBER AND/OR EMAIL ADDRESS FOR EACH REFERENCE. If you do not know the fax number or email address, please get this information before completing the form.

If you do not list a fax number or email address for all references, you will no longer be considered for the housing that is available.
Fax Number:
Please enter a valid phone number.
Email Address:*
example@example.com
Reference #3
Name:*
Relationship to Applicant:*
Phone Number:*
Please enter a valid phone number.
YOU MUST PROVIDE A FAX NUMBER AND/OR EMAIL ADDRESS FOR EACH REFERENCE. If you do not know the fax number or email address, please get this information before completing the form.

If you do not list a fax number or email address for all references, you will no longer be considered for the housing that is available.
Fax Number:
Please enter a valid phone number.
Email Address:*
example@example.com
RESIDENCY HISTORY/LANDLORD INFORMATION
Select One:*

I have lived with my parents my whole lifeI have lived on my own in either a rental or bought a home
Current Address*

Street

Apartment/Unit/Lot

CityState

Zip
Do you own or rent?*

OwnRent
Monthly Payment:*
Are utilities included?*

YesNo
Dates you have lived at this address. From: MM/YYYY* to MM/YYYY*.

Example: If you moved here in August 2018 and currently live here, you would enter: "08/2018" in the first blank and "Current" in the second blank.
Reason for Moving:*
Current Landlord's Name:*
Current Landlord's Email Address:*
example@example.com
Current Landlord's Phone Number:*
Please enter a valid phone number.
Current Landlord's Fax Number:
Please enter a valid phone number.
Do you have previous addresses that you can provide?*

YesNo
How many?*

12
Previous Address:*

Street

Apartment/Unit/Lot

CityState

Zip
Did you own or rent at this address?*

OwnRent
What was your monthly payment?*
Were utilities included?*

YesNo
Dates you lived at this address. From: MM/YYYY* to MM/YYYY*

Example: If you moved here in November 2016 and moved out in August 2018, you would enter: "11/2016" in the first blank and "08/2018" in the second blank.
Reason for Moving:*
Previous Landlord's Name:*
Previous Landlord's Email Address:
example@example.com
Previous Landlord's Phone Number:
Please enter a valid phone number.
Previous Landlord's Fax Number:
Please enter a valid phone number.
Previous Address:*

Street

Apartment/Unit/Lot

CityState

Zip
Did you own or rent at this address?*

OwnRent
What was your monthly payment?*
Were utilities included?*

YesNo
Dates you lived at this address. From: MM/YYYY*to MM/YYYY*

Example: If you moved here in March 2015 and moved out in October 2016, you would enter: 03/2015 in the first blank and 10/2016 in the second blank.
Reason for Moving:*
Previous Landlord's Name:*
Previous Landlord's Email Address:
example@example.com
Previous Landlord's Phone Number:
Please enter a valid phone number.
Previous Landlord's Fax Number:
Please enter a valid phone number.
I, the undersigned, do hereby give Northwest Minnesota Multi-County HRA permission to do a reference, credit, and criminal background check for the purpose of renting from Northwest Minnesota Multi-County HRA.

I understand I have the write to withdraw this permission at anytime.
Applicant's Printed Name:*
Today's Date:*

MonthDayYear
Date
Applicant's Signature:*

Clear
Is there a Co-Applicant listed on this form?*

YesNo
Co-Applicant's Printed Name:*
Today's Date:*

MonthDayYear
Date
Co-Applicant's Signature:*

Clear
Should be Empty:

Reference Sheet

APPLICANT INFORMATION

EVICTION DISCLOSURE

CO-APPLICANT INFORMATION

PROFESSIONAL REFERENCES

Reference #1

Reference #2

Reference #3

RESIDENCY HISTORY/LANDLORD INFORMATION