Verification of Current Residency




(Print and complete this form prior to coming into our office for your initial interview)


Date: __________

Applicant’s Name: ____________________________Last 4 of Primary’s SS#: _______

Current Address: ______________________________________________ Apt # _____

City/State/Zip: __________________________________________________________




Current Landlord/Mortgage Co:______________________________________________

Loan number (if applicable): ________________________________________________

Current Landlord/Mortgage Co. Phone:_________________    Fax: _________________


If less than two years at current address please complete this section

Previous Address: ____________________________________________ Apt #_______

City/State/Zip _____________________________________ Dates: from_____ to ____

Previous Landlord: _______________________________________________________

Previous Landlord’s Phone: ____________________ Fax:________________________


I authorize Realty Ambassadors to contact my current and previous Landlord/Mortgage Co. for the purpose of verifying rental/mortgage history. I authorize my current/previous Landlord/Mortgage Co. to provide Realty Ambassadors and or its representatives any all information requested regarding my rental history and maintenance of my rental unit.


Applicant(s) Signature(s): ________________     _________________ Date: ________



Landlord Please complete


Person Verifying: _________________________________Title ___________________

Are you the current _____   or previous _____ Landlord? Please check one

Property is a Single Family Residence ______ Town House ______ Apartment ______

Dates of Residence: From ________    To: _________

Rental History:

0-30   Days Late: How many times ____ How many days: _____

30-60 Days Late: How many times ____ How many days: _____

Did Tenant(s) give notice before vacating?_______ Were they Evicted?: Y ____ N _____

No. NSF Checks: ____ Would you rent to Tenant again: Y _____ N ______

Was the rental unit maintained to your satisfaction Y_____ N _______

Was the yard maintained to your satisfaction Y ____ N _____ N/A _____

Was / will the entire security deposit (be) refunded? Y _____ N_____

Comments: _____________________________________________________________




Verified by: Signature ____________________________________ Date: __________


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