Nebraska Rental Application

Property Address: [[Property Full Street Address, City, Nebraska, ZIP Code]]
Requested Monthly Rent: $[[Monthly Rent 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 Property Management Company Name]]
Phone: [[Landlord Phone Number]] | Email: [[Landlord Email Address]]

This Rental Application is submitted to evaluate the applicant(s) for tenancy. All information is collected for screening purposes only and will be handled in accordance with the Fair Credit Reporting Act (FCRA), the federal Fair Housing Act, and the Nebraska Residential Landlord and Tenant Act (Neb. Rev. Stat. § 76-1401 et seq.).

Key Disclosures
- Nebraska law imposes no statutory cap on application or screening fees. The fee stated above is non-refundable regardless of the approval decision.
- A consumer report (credit, criminal background, eviction history, rental history) may be obtained.
- The applicant has the right to obtain a copy of any consumer report used and to dispute inaccurate information with the reporting agency.
- Approval decisions may be based on credit history, rental history, criminal background, income, and other lawful criteria applied consistently.
- This application does not create a tenancy or guarantee approval.

All variable user-supplied information appears as `[[Token Name]]` placeholders.

1. Applicant Personal and Contact Information

Applicant Full Legal Name: [[Applicant Full Legal Name]]
Date of Birth: [[Date of Birth (MM/DD/YYYY)]]
Social Security Number: [[Full SSN for screening purposes only, will be handled per FCRA]]
Driver's License or State ID: [[State]] [[License or ID Number]]
Current Phone Number: [[Applicant Primary Phone]]
Email Address: [[Applicant Email Address]]
Current Residential Address: [[Current Street Address, City, State, ZIP Code]]
Length of Time at Current Address: [[Years and Months at Current Address]]

Previous Addresses (last 3 years, list all)

Emergency Contact
- Full Name: [[Emergency Contact Full Name]]
- Relationship: [[Relationship to Applicant]]
- Phone: [[Emergency Contact Phone Number]]
- Email: [[Emergency Contact Email]]

Proposed Additional Occupants
List every person who will reside in the unit (adults and children):

1. [[Additional Occupant 1 Full Name, Age, Relationship]]

2. [[Additional Occupant 2 Full Name, Age, Relationship]]

3. [[Additional Occupant 3 Full Name, Age, Relationship]]

(Attach additional sheet if more occupants.)

2. Prior Evictions and Rental History Disclosures

Have you or any proposed occupant ever been evicted or had an eviction action filed against you?
[[Yes / No, If yes, provide details including date, location, landlord, and outcome]]

Prior Eviction Details (if any)

Have you ever broken a lease or left a tenancy owing money?
[[Yes / No, If yes, provide full details]]

3. Employment, Income, and Financial Information

Current Employer: [[Current Employer Name]]
Employer Address: [[Employer Street, City, State, ZIP]]
Job Title: [[Job Title]]
Length of Employment: [[Years / Months]]
Supervisor / HR Contact: [[Supervisor or HR Name and Phone]]
Gross Monthly Income: $[[Gross Monthly Income]]

Previous Employer (if current employment less than 2 years): [[Previous Employer Name]], [[Job Title]], [[Dates]], $[[Prior Monthly Income]]

Other Monthly Income Sources (alimony, child support, disability, investments, etc.):
[[Describe other income sources and amounts or state "None"]]

Current Monthly Debt Obligations (rent/mortgage, auto loans, credit cards, student loans, other):

1. [[Debt Type 1, e.g. Car Loan]], $[[Monthly Payment]] remaining [[balance or term]]

2. [[Debt Type 2]], $[[Monthly Payment]]

3. [[Debt Type 3]], $[[Monthly Payment]]

Bankruptcy History: [[Have you filed bankruptcy in the last 7 years? Yes/No. If yes, chapter, date, discharge status.]]

4. Credit, Background, and Screening Authorization (FCRA)

Authorization and Consent for Consumer Reports

I/we authorize [[Landlord or Property Management Company Name]] and its designated screening service to obtain consumer reports, including credit reports, criminal background checks, eviction records, employment and income verification, and rental history reports, for the purpose of evaluating this rental application.

I/we understand that:
- This is a consumer report under the Fair Credit Reporting Act (15 U.S.C. § 1681).
- If an adverse action is taken based in whole or in part on information in a consumer report, I/we will receive a copy of the report and a summary of my/our rights.
- I/we may obtain a free annual credit report at www.annualcreditreport.com.
- I/we may dispute inaccurate information directly with the consumer reporting agency.

Applicant Certification
By signing below, I certify under penalty of perjury that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any material misrepresentation may result in denial of the application or termination of any resulting tenancy.

Full Legal Name (matches ID): [[Applicant Full Legal Name]]
SSN: [[Full Social Security Number]]
Date of Birth: [[Date of Birth]]

Signature / Electronic Authorization

Applicant Signature: _______________________________________________ Date: [[Date]]

Printed Name: [[Applicant Full Legal Name]]

(If co-applicant)

Co-Applicant Signature: _______________________________________________ Date: [[Date]]

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

5. Pets, Vehicles, and Other Occupant Information

Pets: [[Will you have pets? Yes/No. If yes: number, type, breed, weight, age. Note: additional pet deposit or rent may apply per property rules.]]

Vehicles: [[Number of vehicles. Make/Model/Year/License for each or state "None"]]

Smoking: [[Do you or any occupant smoke? Yes/No]]

Special Accommodations or Assistance Animals: [[Describe any requested reasonable accommodation under Fair Housing Act or state "None"]]

6. Screening Criteria Notice and Fair Housing Compliance

This property uses objective, consistently applied screening criteria including but not limited to:
- Income at least [[X]] times the monthly rent (or other stated multiple)
- Credit score or history meeting minimum thresholds
- Positive prior rental references
- No recent evictions or patterns of lease violations
- Criminal background review consistent with HUD guidance on individualized assessment

Denials may occur based on credit history, rental history, or criminal background as permitted by law.

Fair Housing Notice
We comply with the federal Fair Housing Act (42 U.S.C. § 3604). We do not discriminate on the basis of race, color, national origin, religion, sex, familial status, or disability. If you believe you have been discriminated against, you may file a complaint with HUD or the Nebraska Equal Opportunity Commission.

7. Additional Questions and Certifications

Are you or any proposed occupant a registered sex offender? [[Yes / No, If yes, jurisdiction and details]]

Have you ever been convicted of a felony? [[Yes / No, details if yes, including dates and nature of offense]]

Do you have any current or pending legal actions that could affect your ability to pay rent? [[Yes / No, explain]]

References (non-family, preferably prior landlords or employers)

1. Name: [[Reference 1 Name]], Phone: [[Reference 1 Phone]], Relationship: [[Reference 1 Relationship]]

2. Name: [[Reference 2 Name]], Phone: [[Reference 2 Phone]], Relationship: [[Reference 2 Relationship]]

8. Applicant Acknowledgment and Signature

I have read and understand all disclosures in this application. I authorize the procurement of consumer reports and the verification of all information provided. I understand that false statements may result in rejection of this application or eviction if tenancy is granted.

Primary Applicant

Signature: __________________________________________________ Date: [[Signature Date]]

Printed Name: [[Applicant Full Legal Name]]

Co-Applicant (if applicable)

Signature: __________________________________________________ Date: [[Signature Date]]

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

Template example, not professional (legal/financial/medical) advice. This is a sample rental application template. Screening criteria, fees, and procedures must comply with current Nebraska law and federal requirements. Verify all practices against Neb. Rev. Stat. § 76-1401 et seq. and applicable HUD guidance before use. Information current as of June 2026.

*End of Nebraska Rental Application*