Location of Rental Desired?      Number of Bedrooms Desired?

Your Name: Your Phone:Your Email:

Current Address:Current Landlord:Current Landlord Phone:

Monthly Rent:Utilities (if separate): Length of time?

Previous Address:Previous Landlord:Previous Landlord Phone:

Monthly Rent:Utilities (if separate): Length of time?

Previous Address:Previous Landlord:Previous Landlord Phone:

Monthly Rent:Utilities (if separate): Length of time?

List All Persons who will occupy the apartment including applicant:

Income Information: (Social Security, SSI, DI, Pensions, Child Support, AFDC, Alimony, Food Stamps, General Assistance, etc.)** Please include salaries of anyone 18 years of age and older.

Name: Income Source: Gross Monthly Income:

Name: Income Source: Gross Monthly Income:

Name: Income Source: Gross Monthly Income:

Name: Income Source: Gross Monthly Income:

Name: Income Source: Gross Monthly Income:

Name: Income Source: Gross Monthly Income:

Assets:

Bank Name: Account Number: Account Balance:

Bank Name: Account Number: Account Balance:

Bank Name: Account Number: Account Balance:

Personal (non-related) and/or Business References: (Name, Address, & Phone):

Name: Address: Phone:

Name: Address: Phone:

Name: Address: Phone:

Do you have a current section 8 certificate and/or voucher? Yes No

Do you have Pets? Yes No If yes, Describe:

Have you or anyone in this household been a defendant in a housing court case? Yes No

Have you or anyone in this household ever been arrested in a drug related offense? Yes No

Have you or anyone in this household ever been arrested for a sex related or violent behavior offense? Yes No

Please note that this is a preliminary application. Additional information may be requested at a later date to complete the processing of applicants. Your signature gives consent to the property owner/agent to verify the information contained in this application. I / We have read the foregoing and certify that the information herein submitted by me/us is true and correct.

Warning: Section 1001 of Title 1B of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any department or agency of the U.S. as to any matter within its jurisdictions.

Applicant Signature: Date:

Applicant Signature: Date:

John Pedro Real Estate Associates

77 Winsor Street, Suite 302 Ludlow, Massachusetts 01056