Mississippi Rental Application

Property Address: [[Property Full Address]], [[City]], Mississippi [[ZIP Code]]
Monthly Rent: $[[Monthly Rent Amount]]
Security Deposit: $[[Security Deposit Amount]]
Desired Move-In Date: [[Desired Move-In Date]]
Application Date: [[Application Date]]
Application / Screening Fee: $[[Application Fee Amount]] (non-refundable)

Landlord / Property Manager: [[Landlord or Management Company Full Name]]
Phone: [[Landlord Phone Number]] | Email: [[Landlord Email Address]]

This Rental Application is submitted to evaluate the Applicant(s) for tenancy at the Property. All information will be used solely for tenant screening in compliance with the federal Fair Housing Act (42 U.S.C. § 3601 et seq.), the Fair Credit Reporting Act (FCRA, 15 U.S.C. § 1681 et seq.), and applicable Mississippi law. Mississippi follows federal fair housing prohibitions on discrimination based on race, color, national origin, religion, sex, familial status, and disability. Criminal background screening must be applied consistently and in accordance with HUD guidance to avoid disparate impact.

Key Disclosures (Read Before Completing)
- The application fee amount is disclosed above. It is non-refundable regardless of whether the application is approved or denied.
- A consumer report (credit, criminal, eviction history, etc.) and/or investigative consumer report may be obtained.
- Applicant has the right under FCRA to obtain a copy of any consumer report obtained about Applicant and to dispute the accuracy of information in the report.
- This application does not create a tenancy, obligate the Landlord to rent, or guarantee approval. Decisions are based on consistently applied, objective screening criteria including but not limited to income, credit, rental history, and criminal background (subject to individualized assessment where required).
- All proposed occupants age 18 and over must submit a separate application unless otherwise agreed.

All variable user values are expressed as `[[Token Name]]` placeholders. No pre-filled sample data., -

1. Applicant Personal / Contact Information and Residency History

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

Date of Birth: [[Date of Birth]]

Social Security Number: [[Full SSN, required for screening]] (last four digits may be used on initial form; full number required on authorization)

Driver's License or Government-Issued Photo ID: [[State]] [[ID Number]]

Current Phone Number: [[Applicant Phone Number]]

Email Address: [[Applicant Email]]

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

Length of Time at Current Address: [[Months or Years at Current]]

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

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

Monthly Rent at Current Address: $[[Current Monthly Rent]]

Reason for Moving: [[Reason for Moving]]

Previous Addresses (last 3 years, attach additional pages if needed):

Proposed Additional Occupants (all persons who will reside in the unit, including children):

[[Full names, dates of birth or ages, and relationship to Applicant for all proposed occupants. If none other than Applicant(s), state "None."]]

Emergency Contact (not residing at the Property):
- Name: [[Emergency Contact Full Name]]
- Relationship: [[Relationship to Applicant]]
- Phone: [[Emergency Contact Phone]]
- Email: [[Emergency Contact Email]], -

2. Employment and Income Verification

Current Employer: [[Current Employer Name]]

Employer Address: [[Employer Address]]

Position / Job Title: [[Job Title]]

Supervisor or HR Contact: [[Supervisor Name and Phone]]

Length of Employment: [[Years / Months at Current Job]]

Monthly Gross Income (before deductions): $[[Monthly Gross Income]]

Other Monthly Income Sources (SSI, pension, alimony, child support, investments, etc.): [[Other Income Description and Amount or "None"]]

If Current Employment Less Than 2 Years, Provide Previous Employment:

• Previous Employer: [[Previous Employer]]
• Dates: [[Previous Employment Dates]]
• Monthly Gross: $[[Previous Monthly Gross]]
• Reason for Leaving: [[Reason]]

Total Combined Monthly Gross Household Income: $[[Total Monthly Gross Household Income]]

Income Qualification Standard Applied: Minimum gross monthly income of approximately [[Income Multiple, e.g., 3]] times the monthly rent (subject to other factors such as credit and debt-to-income).

Proof of Income Applicant Will Provide (check all that apply):
- [ ] Last two (2) pay stubs
- [ ] Last two (2) years W-2s, 1099s, or tax returns (first two pages)
- [ ] Most recent bank or investment statements (last 3 months)
- [ ] Award letters or verification for government benefits
- [ ] Other: [[Other Proof Description]], -

3. SSN / ID Authorization and FCRA / Background Consent

Authorization for Consumer Report and Background Screening

I/We, the undersigned Applicant(s), authorize the Landlord, its agents, employees, or screening service to obtain one or more consumer reports, credit reports, criminal background checks, eviction history reports, and/or investigative consumer reports about me/us for tenant screening purposes. This authorization is valid for the period required to process this application and any updates or re-screening if needed.

I/We understand that:

1. The report(s) may include information regarding credit history, criminal convictions and arrests (subject to applicable law and time limits), eviction filings and judgments, employment verification, and rental history.

2. Under the FCRA, I/we have the right to obtain a free copy of any consumer report obtained if the request is made within 60 days of adverse action or at any time for a fee from the reporting agency.

3. I/we have the right to dispute the accuracy or completeness of any information in a consumer report directly with the consumer reporting agency.

4. A copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" will be provided upon request or with any adverse action notice.

Applicant Signature on Authorization: (see signature section at end), -

4. Rental History and Landlord References

Current or Most Recent Landlord Reference (required):
- Landlord / Property Manager: [[Current or Most Recent Landlord Name]]
- Phone and/or Email: [[Landlord Contact Info]]
- Property Rented: [[Address of Rented Unit]]
- Monthly Rent: $[[Rent Amount There]]
- Dates Occupied: [[From Date]] to [[To Date]]
- Did Applicant provide proper notice to vacate? [[Yes / No]]
- Any unpaid rent, damages, or lease violations? [[Yes, provide details: [[Details]] / No]]

Additional Landlord Reference (within last 3 years):
- Landlord Name: [[Additional Landlord Name]]
- Phone / Email: [[Contact]]
- Property: [[Address]]
- Dates: [[Dates]]
- Notes: [[Any issues or positive notes]]

Has Applicant ever been evicted or had an eviction action filed against Applicant? [[Yes, explain dates, jurisdiction, outcome: [[Eviction Explanation]] / No]]

Has Applicant ever been a party to a lawsuit involving a landlord or property? [[Yes, details: [[Lawsuit Details]] / No]], -

5. Credit and Financial Information

Applicant authorizes verification of credit and financial information as part of screening.

Approximate Credit Score Range (self-reported, optional): [[Excellent / Good / Fair / Poor / Prefer Not to State]]

Bankruptcy Filed in Last 7 Years? [[Yes, chapter and discharge date: [[Bankruptcy Details]] / No]]

Outstanding Judgments, Collections, or Liens? [[Yes, describe: [[Financial Obligations Details]] / No]]

Vehicles to Be Parked at Property (make, model, year, license plate):
[[Vehicle 1 Description]]
[[Vehicle 2 Description or "None"]], -

6. Criminal Background Information

Note: Criminal background screening is conducted consistently with the Fair Housing Act and HUD guidance on the use of criminal records in housing (2016 guidance and subsequent updates). Blanket bans on all criminal history are not used. Individualized assessments consider the nature, recency, and severity of the offense and any mitigating information provided by the Applicant. Certain convictions (e.g., those involving violence, sexual offenses against children, or manufacture/distribution of controlled substances on the premises) may be disqualifying. Applicants will be given an opportunity to provide evidence of rehabilitation or mitigating circumstances before a final decision.

Has Applicant ever been convicted of a felony? [[Yes, provide details including charge, jurisdiction, year, and current status: [[Felony Details]] / No]]

Has Applicant ever been convicted of a misdemeanor involving violence, drugs, theft, fraud, or property damage within the last [[Lookback Period, e.g., 7]] years? [[Yes, details: [[Misdemeanor Details]] / No]]

Is Applicant currently on probation, parole, or registered as a sex offender? [[Yes, details: [[Probation or Registry Details]] / No]]

Pending criminal charges? [[Yes, details: [[Pending Charges Details]] / No]], -

7. Pets, Occupants, and Additional Information

Will Applicant have pets? [[Yes / No]]

If yes:
- Type, breed, weight, age: [[Pet Description(s)]]
- Number of pets: [[Number]]
- Service or assistance animal (not subject to pet policy or fees): [[Yes, describe and provide documentation if requested / No]]

Smoking Policy Preference / Disclosure: [[Applicant is / is not a smoker. Applicant agrees to comply with Property smoking policy.]]

Has Applicant ever been convicted of manufacturing or distributing illegal drugs? [[Yes / No]]

Any other information Applicant wishes Landlord to consider (e.g., explanations of credit issues, employment gaps, or mitigating factors): [[Additional Applicant Statement or "None"]], -

8. Fair Housing and Nondiscrimination Notice

Landlord complies with the federal Fair Housing Act and does not discriminate on the basis of race, color, national origin, religion, sex, familial status, or disability. Mississippi law also prohibits housing discrimination on these bases. Reasonable accommodations and modifications will be provided upon request for persons with disabilities, subject to applicable verification.

If Applicant believes Applicant has been discriminated against, Applicant may contact the U.S. Department of Housing and Urban Development (HUD) or the Mississippi Center for Justice or other appropriate fair housing organizations., -

9. Application Fee and Payment

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

This fee covers the cost of processing the application and obtaining consumer reports and is non-refundable. Payment method: [[Check / Money Order / Online Payment / Other, [[Specify]]]]

Fee Receipt / Payment Confirmation Number: [[Payment Confirmation or "To be provided"]], -

10. Applicant Certification and Signatures

I/We certify that all information provided in this Mississippi Rental Application is true, complete, and accurate to the best of my/our knowledge. I/We understand that any false, incomplete, or misleading information may result in denial of the application or termination of any tenancy granted. I/We authorize verification of all information provided, including but not limited to employment, income, rental history, credit, and criminal background, and release all parties from liability for providing such information.

Applicant 1 Signature: _______________________________ Date: [[Signature Date]]

Printed Name: [[Applicant Full Legal Name]]

Applicant 2 Signature (if joint application): _______________________________ Date: [[Signature Date]]

Printed Name: [[Second Applicant Full Legal Name]], -

11. Landlord Use Only, Screening Summary (Not Part of Applicant Form)

Date Received: [[Date]]

Application Fee Received: [[Yes / No]] Amount: $[[Amount]]

Screening Completed By: [[Screening Processor]]

Credit / Background Report Ordered: [[Date]]

Decision: [[Approved / Denied / Approved with Conditions]]

Reason(s) for Denial (if applicable, must be specific and provided to Applicant per FCRA if adverse action taken):

[[Denial Reasons or Conditions]]

Adverse Action Notice Provided (if required): [[Date / Method]], -

Mississippi Rental Application, Compliance and Disclaimer

This form is designed for use in Mississippi and incorporates federal Fair Housing Act requirements and FCRA protections. There is no statewide statutory cap on application fees in Mississippi; the disclosed fee must be reasonable in relation to actual screening costs. Criminal background screening should follow HUD guidance to avoid unjustified disparate impact on protected classes. This document is a template and does not constitute legal advice. Landlords should apply screening criteria consistently, maintain records, and consult a licensed attorney or fair housing professional regarding specific policies, adverse action notices, and any updates to federal or state requirements. Information is current as of the specifications provided and June 2026., -

End of Mississippi Rental Application