Senior Citizen Housing Lease Application
Applicant Information
Full Name
Date of Birth
Social Security Number
Phone Number
Email Address
Current Address
Residency Status
Are you a U.S. Citizen?
Yes
No
Income Information
Monthly Income
Primary Source of Income
Other Sources of Income
Housing History
Current Landlord Name
Landlord Phone
Previous Address (if any)
Medical/Emergency Contacts
Primary Doctor Name
Doctor Phone
Emergency Contact Name
Emergency Contact Phone
Legal Disclosures
Have you ever been convicted of a crime?
Yes
No
Have you ever been evicted from any residence?
Yes
No
Additional Information
Anything else we should know?
Applicant Signature
Signature
Date