Date:
PERSONAL INFORMATION:
1. Your Name and Contact Information:
a.Name:

b.E-mail:

c.Telephone:
c1. Landline

c2. Cell

2.a What type of renter`s assistance are you seeking?
Security DepositFirst Month's RentBoth
b. Approximate dollar amount needed:

c. Briefly describe why you are in need of such assistance and any extenuating circumstances that support the need at this time:

d. Have you ever been charged with or convicted of a felony (please note that a “Yes” will not preclude you from assistance, but further information will be requested)?
YesNo
EMPLOYMENT INFORMATION:
1. Your Employer's name, hereafter to be referred to as COMPANY – will only contact with your written or email consent only to be requested at the final phase of approval:

2. Please provide the following information about the COMPANY:
a. Address:

b1. Name of your immediate supervisor:

b2. Title of your immediate supervisor:

c. Telephonenumber of:
c1. Company

c2. Supervisor

d. E-mail of Supervisor:

e. How long have you worked for the COMPANY and what are your job responsibilities:

f. Your approximate monthly earnings:

e. Will you provide documentation demonstrating your monthly earnings and length of employment at a later date?
YesNo
REFERENCE INFORMATION
Please provide 2 personal references.
1. Reference #1
a. Name:

b. E-mail:

c. Address:

d. Telephone:
d1. Landline

d2. Cell

2. Reference #2
a. Name:

b. E-mail:

c. Address:

d. Telephone:
d1. Landline

d2. Cell

AGREEMENT TO CONDITIONS FOR ASSISTANCE
Do you agree that any funds provided will be paid directly to the landlord or leasing broker and you will agree in writing with the landlord or leasing broker that the security deposit will be paid back directly to HHYH at the end of the lease term
YesNo
Do you agree to sign an agreement with HHYH whereby you commit to maintaining the property in outstanding condition including maintaining the interior and exterior condition of the property, abiding by all terms of the lease and if there are any problems or concerns, you will immediately contact HHYH to inform us.
YesNo
SIGNATURE AND CERTIFICATION
I HEREBY DECLARE THAT THE INFORMATION PROVIDED HEREIN IS ACCURATE, UPDATED, AND COMPLETE. I HEREBY DULY AUTHORIZE YOUR COMPANY AND/OR ITS REPRESENTATIVES AND/OR ITS AGENTS, FOR THE PERIOD OF 180 DAYS, TO VERIFY THE INFORMATION PROVIDED HEREIN, INCLUDING ALL REFERENCES; CRIMINAL AND/OR COURT RECORDS; CONDUCT AND/OR CONTRACT INVESTIGATIVE REPORTS WHICH CAN INCLUDE CREDIT STANDING, CREDIT CAPACITY, CHARACTER AND/OR GENERAL REPUTATION, EDUCATION BACKGROUND, EMPLOYMENT/WORK HISTORY AND CREDIT HISTORY, AMONG OTHERS AND HEREBY HOLD HARMLESS ALL OF THE PERSONS AND AGENCIES PROVIDING SUCH INFORMATION FROM ANY AND ALL CLAIMS AND DAMAGES CONNECTED WITH THEIR RELEASE OF INFORMATION.
I HEREBY AGREE TO PROMPTLY INFORM YOU REGARDING ANY MATERIAL CHANGE TO THE INFORMATION PROVIDED.
I HEREBY ACKNOWLEDGE THAT THIS QUESTIONNAIRE WILL BE DEEMED TO BE DULY EXECUTED BY MY COMPLETING THIS FORM, AND EITHER ELECTRONICALLY TYPING IN MY NAME ON THE SIGNATURE LINE, OR PRINTING, SIGNING, AND SENDING BACK A COMPLETED FORM.
Signature

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