Worthington Market Rate Application

Application to Rent
Worthington HRA

819 Tenth Street, Worthington, MN 56187 | Phone 507-376-3655
Preferred Number of Bedrooms
Applicant

Each Applicant over the age of 18 must complete their own application form
Name

First NameMiddle NameLast Name
Other Names Used in the Last 10 Years

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security #
Driver's License #
Main Phone
Format: (000) 000-0000.
Additional Phone
Format: (000) 000-0000.
Email
example@example.com
Additional Occupants

List everyone who will live with you
First, Middle, Last Name
Social Security #
Date of Birth

MonthDayYear
Date
Relationship To Applicant
First, Middle, Last Name
Social Security #
Date of Birth

MonthDayYear
Date
Relationship To Applicant
First, Middle, Last Name
Social Security #
Date of Birth

MonthDayYear
Date
Relationship To Applicant
First, Middle, Last Name
Social Security #
Date of Birth

MonthDayYear
Date
Relationship To Applicant
First, Middle, Last Name
Social Security #
Date of Birth

MonthDayYear
Date
Relationship To Applicant
Employment
Current Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Employer Phone
Format: (000) 000-0000.
Current Job Title
Current Name of Supervisor
Start Date of Employment

MonthDayYear
Date
End Date of Employment

MonthDayYear
Date
Income Per Month
Prior Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Employer Phone
Format: (000) 000-0000.
Prior Job Title
Prior Name of Supervisor
Start Date of Employment

MonthDayYear
Date
End Date of Employment

MonthDayYear
Date
Income Per Month
Current Residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Stay (starting)

MonthDayYear
Date
Date of Stay (ending)

MonthDayYear
Date
Owner/Manager
Owner/Manager Phone Number
Format: (000) 000-0000.
Reason For Leaving
Last Rent Paid
Previous Residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Stay (starting)

MonthDayYear
Date
Date of Stay (ending)

MonthDayYear
Date
Owner/Manager
Owner/Manager Phone Number
Format: (000) 000-0000.
Reason For Leaving
Last Rent Paid
Previous Residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Stay (starting)

MonthDayYear
Date
Date of Stay (ending)

MonthDayYear
Date
Owner/Manager
Owner/Manager Phone Number
Format: (000) 000-0000.
Reason For Leaving
Last Rent Paid
Vehicles
Make
Model
Color
Year
License No.
Make
Model
Color
Year
License No.
Make
Model
Color
Year
License No.
Personal References
Emergency Contact Name
Emergency Contact Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Close Friend
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Relationship
Nearest Relative Living Elsewhere
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Relationship
Credit Information

Please list all your financial obligations
Name of Bank or Savings & Loan
Branch or Address
Check Account No.
Balance
Name of Bank or Savings & Loan
Branch or Address
Savings Account No.
Balance
Credit Accounts
Account No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Balance
Due Monthly
Credit Accounts
Account No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Balance
Due Monthly
Credit Accounts
Account No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Balance
Due Monthly
Credit Accounts
Account No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Balance
Due Monthly
Credit Accounts
Account No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Balance
Due Monthly
General Information

Check answer that applies

Rows	Answer
Do you smoke?
Do you have any pets?
Have you ever filed for bankruptcy?
Do you have any musical instruments?
Do you have any water-filled furniture or do you intend to use water-filled furniture in the apartment?
Have you ever been convicted for selling, possessing, distributing or manufacturing illegal drugs or convicted of any other crime?
Have you ever been evicted for non-payment of rent or any other reason?

Please explain any "Yes" answers to the above questions:
Why are you leaving your current residence?
A $25 application fee is required for the cost of processing this application, to obtain credit history and other background information.
I accept the below statement
I accept the below statement

Applicant represents that all information given on this application is true and correct. Applicant hereby authorizes verification of all references and facts, including but not limited to current and previous landlords and employers, and personal references. Applicant hereby authorizes owner/agent to obtain Unlawful Detainer, Credit Reports, Telechecks, and/or criminal background reports. Applicant agrees to furnish additional credit and/or personal references upon request. Applicant understands that incomplete or incorrect information provided in the application may cause a delay in processing which may result in denial of tenancy. Applicant hereby waives any claim and releases from liability any person providing or obtaining said verification or additional information.
I accept the below statement

I authorize the Worthington Housing Authority/Prairie Acres/Rising Sun Estates to obtain a Consumer Credit Report and/or a Background Report on me. This authorization is valid for purposes of verifying information given pursuant to employment, leasing, rental, business negotiation, or any other lawful purpose covered under the Fair Credit Reporting Act (FCRA). The Background Check may contain information available in the Public Domain but may not include interviews with persons other than previous employers or their agents. By accepting above, I hereby authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts and agencies, military services and persons to release all information they may have about me including criminal and driving history. This authorization shall be valid in original or copy form.
Please upload a copy of a valid Drivers License

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Worthington HRA