Connecticut Rental Application and Screening Authorization

Property Applying For: [[Property Full Address, City, Connecticut ZIP]]

Landlord / Property Manager: [[Landlord or Management Company Name]]

Application Date: [[Application Date]]

This is a rental application for the above Property. All information provided will be used solely for screening purposes in accordance with applicable law, including the Fair Credit Reporting Act (FCRA), Connecticut General Statutes, and fair housing laws.

Connecticut prohibits landlords from charging application fees in excess of the actual costs of screening (CGS § 47a-21). Landlords must provide applicants a copy of any consumer report used in the decision (CGS § 36a-696). Discrimination based on lawful source of income is prohibited. Many Connecticut municipalities have fair-chance housing ordinances that restrict inquiries into or consideration of certain criminal history.

1. Applicant Information

Full Legal Name: [[Applicant Full Legal Name]]

Date of Birth: [[Date of Birth]] Social Security Number (last 4 for verification): [[SSN Last 4 or Full SSN if required for screening]]

Current Address: [[Current Street Address, City, State, ZIP]]

Phone: [[Primary Phone]] Email: [[Email Address]]

Driver's License / State ID: [[DL or ID Number and State]] Expiration: [[Expiration Date]]

Are you a U.S. citizen or lawful permanent resident? [[Yes / No, if No, provide immigration status documentation]]

2. Household Members and Occupants

List all persons who will reside in the unit (including children):

Total number of occupants: [[Total Occupants]]

3. Residency History

Current Landlord / Property Manager: [[Current Landlord Name or Company]]

Current Landlord Phone / Email: [[Landlord Contact Phone / Email]]

Current Monthly Rent: [[Current Monthly Rent Amount]] Length of Tenancy: [[Years / Months at Current Address]]

Reason for Leaving: [[Reason for Moving]]

Previous Address (if within last 5 years): [[Previous Address]]

Previous Landlord: [[Previous Landlord Name]] Phone: [[Previous Landlord Phone]]

Dates at Previous: [[From Date, To Date]]

Have you ever been evicted or had an eviction filed against you? [[Yes / No]] If yes, explain: [[Explanation]]

Have you ever been asked to vacate or left owing rent or damages? [[Yes / No]] If yes, explain: [[Explanation]]

4. Employment and Income

Current Employer: [[Current Employer Name]]

Employer Address: [[Employer Address]]

Position / Title: [[Job Title]] Supervisor / HR Contact: [[Supervisor Name and Phone]]

Dates Employed: [[Employment Start Date]] to Present

Gross Monthly Income: $[[Gross Monthly Income Amount]]

Other Income Sources (alimony, child support, disability, investments, etc.): [[Other Income Description and Amount]]

Previous Employer (if current employment < 2 years): [[Previous Employer]] Dates: [[Dates]]

Total household gross monthly income: $[[Total Household Gross Monthly Income]]

5. Financial Information and Credit Authorization

Bank Name: [[Bank Name]] Account Type: [[Checking / Savings]]

Do you have any outstanding judgments, tax liens, or bankruptcy filings in the last 7 years? [[Yes / No]] If yes, provide details and dates: [[Details]]

Have you ever been convicted of a felony? [[Yes / No]] (Note: Connecticut and many local fair-chance rules limit when and how criminal history may be considered. You are not required to disclose sealed, erased, or pardoned records.)

If yes, provide details including date, jurisdiction, and nature: [[Criminal History Details, or "N/A"]]

6. Screening Fee Disclosure and Authorization

Application / Screening Fee: $[[Screening Fee Amount]]

This fee is limited to the actual out-of-pocket costs incurred by Landlord for consumer reports, background checks, and related screening services (CGS § 47a-21). The fee is [[Refundable / Non-refundable, explain conditions]].

By signing below, Applicant authorizes Landlord or its agent to obtain one or more consumer reports (credit report, criminal background, eviction history, and/or rental references) from consumer reporting agencies. Landlord will provide Applicant with a copy of any consumer report used in making the rental decision upon request (CGS § 36a-696 and FCRA).

Applicant understands that a consumer report may be obtained for this application and for any renewal or future tenancy-related decisions.

7. References

Personal Reference 1: [[Name]] Relationship: [[Relationship]] Phone: [[Phone]]

Personal Reference 2: [[Name]] Relationship: [[Relationship]] Phone: [[Phone]]

Emergency Contact: [[Name]] Relationship: [[Relationship]] Phone: [[Phone]]

8. Vehicle and Pet Information (if applicable)

Vehicles to be parked on premises: [[Year / Make / Model / Plate, or "None"]]

Pets (type, breed, weight, age): [[Pet Details or "No Pets"]]

Service or assistance animals (do not require pet deposit or fee when documented): [[Service Animal Details or "N/A"]]

9. Additional Questions and Disclosures

Have you or any household member ever been a registered sex offender? [[Yes / No]] (Landlord may verify via public registry as permitted by law.)

Will any occupant smoke or use tobacco products inside the unit? [[Yes / No]]

Do you or any household member require any reasonable accommodation under fair housing laws? [[Yes / No]] If yes, describe: [[Description]]

Are you applying with a co-applicant or guarantor? [[Yes / No]] If yes, name: [[Co-Applicant or Guarantor Name]]

10. Fair Housing and Nondiscrimination Notice

Landlord does not discriminate on the basis of race, color, religion, sex, national origin, familial status, disability, marital status, age, sexual orientation, gender identity or expression, lawful source of income, veteran status, or any other characteristic protected by federal, Connecticut state, or local law.

Connecticut prohibits discrimination based on lawful source of income (including Section 8 and other housing assistance). Criminal history inquiries and use are restricted under applicable fair-chance housing rules in many Connecticut cities and towns. Landlord will comply with all applicable restrictions.

If you believe you have been discriminated against, you may contact the Connecticut Commission on Human Rights and Opportunities (CHRO) or the U.S. Department of Housing and Urban Development (HUD).

11. Certification and Authorization

I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any false statement or omission may result in denial of tenancy or termination of any lease granted.

I authorize verification of all information provided, including but not limited to credit, criminal, eviction, employment, income, and rental history. I authorize the release of such information to Landlord and its screening agents.

I acknowledge receipt of the screening fee disclosure above and understand my rights under CGS § 47a-21 and CGS § 36a-696.

Applicant Signature: ______________________________ Date: ___________

Print Name: [[Applicant Full Legal Name]]

Co-Applicant / Additional Adult Signature (if applicable): ______________________________ Date: ___________

Print Name: [[Co-Applicant Full Legal Name]]

Landlord / Agent Acknowledgment of Receipt

Received by: ______________________________ Date: ___________

Screening fee received: $[[Amount]] Form of payment: [[Cash / Check / Other]], -

*Sample template for Connecticut, not legal advice. Complies with CGS § 47a-21 (application fees limited to actual screening costs), CGS § 36a-696 (consumer report copy), fair housing protections including lawful source of income, and applicable fair-chance housing rules. Verify current local municipal ordinances and obtain legal advice before use. Statutory references current as of 2026-06.*