Вы находитесь на странице: 1из 4


LANDLORD: Address: Phone#:
South Central \i\fisconsin

MANAGER: Address: Phone #: E-mail (Optional)
South Centra! vVisconsin

1 ~/J1 n.Oj>-=~Tt'a-s.
'7~ i 3 I ~Hj.)JI4-B*Y
!?1;th'Jd;ON I

5371 loog -~358--8939


-S Jlf-iU

E-mail (Optional)

~'I, VYf~tce sIx:-1/~&..(, 1't4

_ _

The undersigned here',by makE~sapplication to rent apartment !-kJVS3 (Unit Number) located at 2-/1 5, l11u-,-s Sr: Monthly Rent: :II 35""<Z? --Lease Term: ONi$ Ye7t-~ Security Deposit: -tS-~, ~ Earnest Money Paid: -

______-I---,---~ 00. ~
-Is17 ~o

:St4 "I( iNC'::{


~ 17:>0 AtJc;.vsr


Each Adult AI!I!/ieaL Must Como/ete a Seoatate ADD/iealion

Complete the fOllowirl\g information for each household member that will occupy the unit at the time of move-in and I throughout the term <,>f lealse. APPLICATION MUST BE COMPLETED IN FULL. FALSIFICATION OF INFORMATION the lS GROUNDS FOR DENIAL. I Birthdate: Number Month/Day/Y ear Social Security Driver's License !\lAME: M/F Number




Daytime Phone Email (Optional):


Evening Phone



1. D'o you expect any additions to the household within the next 12 months?
I I .

Name & Relationship:

2. Have you, or any other person named on this application, ever been convicted of a crime related to di~';turbanCj3of neighbors, destruction of property, drug-related felonious criminal activity or violence to pe'rsons or property? Explanation:

3. DIDyou have or do you anticipate having any pets? Explanation:

4. DIDyou owe past due rent or other monetary obligations to your current landlord or a previous landlord? 5. DIDyou wish to receive a written explanation of denial of tenancy?

Name: Address: Phone #:

Application lor Residency

- Dane County

& City 01 Madison

Revised 12/09

City: City:

CURRENT IADDRESS PREVIOUS ADDRE:SS II -PREVIOUSI ADDRESS No Yes --No Years] From (date): Zip: Yes-From I(date): you To (date):Address: or asked to -- to pay rent? Have State: State: Have ever beenFax#: you ever refused evicted leave?

Car #

1: Primary Driver's Name:

Make/Mode'llYr.lColor: I Plate #:

_ _


Car # 2: Primary Dri,ver's Name: Make/ModellYr.lColor: Plate #:


_ _ Driver's License #:

PLACE OF EMPl'oYMENT: Address: I How long have YOI'J been employed here? (Give dates): From. Gross Monthly Incbme: Supervisor's Name PLACE OF EMPL10YMENT: Address: How long have YOI'J been employed here? (Give dates): From: Gross Monthly Inc'ome: Supervisor's Name

---------------------------------------To: Phone #:

How many hours per week?

_ _


How many hours per week? To: Phone #: ... ... (_ ) How many hours per week? To: Phone #: ... .... (_ )


_ _ _ _ _

PLACE OF EMPL10YMENT: I Address: How long have YOI'J been employed here? (Give dates): From: Gross Monthly Inc:Dme: Supervisor's Name.


Application for Residency - Dane County & City of Madison

Revised 12/09

Will you be receiving! any othE~rincome that you want considered with this application (e.g., Section 8 Rental Assistance, SSI, Social Security,jpUbliC a~~sistance, W-2, alimony, child support, savings, trust funds, scholarships, or any other type of income)? If so, pleaBe providle the following information for verification.

Source Address Contact Amount

of IncomeI (Name, of Agency): of Agency: Person's ,Name: . of InCOmE!. .

_ Phone

#: .. (__



Source of Incomle (Name of Agency): I Address of Agency:

H _._.

Contact Person's IName: '. Amount of Incomo:


#: .. (_--i-)

Self Emploved AlpPlican1:S: If you are self employed you will need to provide the following information: Tax returns, busines:'s Iicens~iJ, bank records and/or vendor names, with addresses and phone numbers for verification


Have you ever filed for bankruptcy? Credit Reference I Address

Yes_No_ Type & Account Number

& Phone #

The purpose of this application is to dlatermine whether I qualify as a tenant. If my application is approved, have no rental agreement ~'viththe Landlord before the time of the lease signing.

the Landlord and I shall sign a written lease.

I have paid the eamest or my first month's rent agreement, the eamest duty to mitigate. If this money deposit indicated on this application. The eamest money deposit will be applied to my security deposit if th'e Landlord enters into a lease or rental agreement with me. If this application is approved, and I fail to enter into a lease or rental mo:ney and any subsequent payments may be retained to compensate the Landlord's costs and damages, subject to the Landlord's application is rejected or withdrawn or if no action is taken by the end of the calendar day following receipt of the eamest

money, the eamest money land any subsequent payments will be refunded by the end of the next business day. I hereby authorize the Landl9rd and Manager to investigate my credit and financial responsibility, income, rental and eviction history, conviction record and the statements made in this appi ication, and to obtain a consumer credit report on me from a consumer reporting agency that compiles and maintains files on consumers on a nationwide basis. My pI'jrformance under any lease or rental agreement that I may enter into with the Landlord may be reported to such reporting agency. I acknowledge that the Mar!lager and the agents and employees thereof represent the interests of the Landlord, but they also have a duty to treat all parties fairty and in accordance wilh fair housing law, and to disclose material adverse facts about the property.

I warrant and represent tha.t J am at least 18 years of age and _ that all information and answers to the above questions are true and complete to the best of my knowledge. I understar'ld that pro'liding false information or making false statements may be grounds for denial of my application. I also understand that such action may result in CI'iminal penalties. I understand that my occupancy is contingent on meeting managemenfs resident selection criteria.


Date Date
- Oane County

Application for Residency

& City of Madison

Revised 12/09

1. 2. 3.

A receipt for ea1mest mon1ay collected has been given applicant. Copies of the p'roposed lease and rules and regulations of the landlord have been made available to applicant for inspection. l/we have been' given the name and address of the person authorized to receive rent, manage, and maintain the premises, who can readily be contacted, andlan owner or agent with an address within the state authorized to receive and receipt for notices and demands, and at which service of process can be made in person. l/we have been' advised of my/our right to inspect the dwelling unit and notify the landlord of any damage or defect that exist before the beginning of my/our tenahcy. IIwe have been' advised of my/our right to request, in writing, a written list of the physical damage and defects, for which the landlord deducted money from thE"previous tenanfs security deposit.
n _____ _. ___

4. 5.


s red SeDaratel',



"- HeatPick-UpWater \ SewerJWater 'Ii. Trash Gas Hot AirLIConditioning









7. 8.

l/we have been advised of uncorrected building and housing code violation notices on the attached list. l/we have been' advised that the remises contain s the followin conditions adversel affectin habitabili Adverse Conditloll1: Yes Ex lain No Hot or Cold Running Wate!r Plumbing Facilities'Not in Good Operating Condition Sewage Disposal Facilities Nut in Good Operating Condition Unsafe Heating Fal::ilities capable of Maintaining a Temperature of 67"F Electrical Wiring, Outlets, Fixtures Not in Safe Operating Condition

9. 10.

IIwe have beenladvised of structural or other conditions in the dwelling unit or premises that present a substantial create an unreasonable risk of personal injury. Landlord promi~';es to repair, clean, or improve the premises as follows by the completion dates noted:, I I

health or safety hazard, or _


Security deposi:!s may be withheld only for tenant damages, waste or neglect of the premises or the non payment of rent, utility services or mobile home parking fE',esfor whic:h the Landlord becomes liable and other reasons specifically and separately negotiated and agreed to by the tenant in writing in a Non'standard Rental Provision. may not be of an applicanfson Social Security decision (SSN) is voluntary, and housing the applicant's Number to withhold their SSN. Disclosure denied solely

12. 13. 14.


16. 17.

IIwe have been ,Iadvised that I/we may submit a written request to the landlord within 30 days to view the photographs maintf,lined by the landlord which documeni': the physical damages or defects that were charged to the security deposit of the previous tenant(s). That a copy of n'otice of eligibility for rent abatement, if any, which affects the rental unit or common areas has been provided the tenant. That the occupa'ncy limit imposed upon the dwelling unit by 27.06 of the City of Madison General Ordinance is . However, occupancy is restricted to tt',ose persons named in the application and the rental agreement. That the definitic'!I1 of a "family" pursuant to 28-03(2) Madison General Ordinances, is as follows: "A family is an individual of two or more persons related by blood', marriage, or legal adoption living together as a single housekeeping unit in a dwelling unit, including foster children, and not more than four (4) roo'mers except that the terms "family" shall not in R1, R2, R3, R4A and R4L residence districts include more than one (1) roomer except where dv:,elling unit is owner occupied. For the purpose of this section "children go means natural children, grandchildren, legally adopted children, stepchi,ldren, foster children, or a ward determined in a legal guardianship proceeding. Up to two (2) personal attendants who provide services for family members or roomers who, because of advanced age or a physical or mental disability, need assistance with activities or daily living shall be cC'lnsidered part of the "family". Such services may include personal care, housekeeping, meal preparation, laundry or companionship. I That the zoning district in which the dwelling unit is located is _ That the off-stre,'at parking requirements of the dwelling unit pursuant to 28-11 Madison General Ordinances is .


Ih. j"""

.<eo ~ PO' ~clJhn 28.07(1){9) hi !he Mad"'n




Date Date


This application has been 'prepared for use by members of the Apartment Association of South Central Wisconsin and the Wisconsin Apartment Association. The Associations are unaj)/e to provide representations or warranties that this application form complies with all current laws or regulations relating to the rental of property. Landfol'ds/agents are advised to consult with legal counsel for /ocal ordinance compliance requirements.


for Residency

- Dane County & City of Madison

Revised 12/09

Похожие интересы