Pennsylvania Rental Application

Property Address: [[Property Full Address]], [[City]], PA [[ZIP Code]]

Monthly Rent: $[[Monthly Rent Amount]]

Security Deposit (max per 68 P.S. §250.511a): $[[Security Deposit Amount, up to 2 months' rent year 1, 1 month thereafter]]

Desired Move-In Date: [[Desired Move-In Date]]

Application Date: [[Application Date]]

Application / Screening Fee: $[[Application Fee Amount]] (non-refundable; see disclosures below)

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

Contact: [[Landlord Phone]] | [[Landlord Email]]

This Rental Application is used to evaluate applicants for tenancy at the above-referenced property. All information provided will be used solely for screening purposes in accordance with the Fair Credit Reporting Act (FCRA, 15 U.S.C. §1681 et seq.), the Fair Housing Act (42 U.S.C. §3604), the Pennsylvania Human Relations Act (PHRA), and the Pennsylvania Landlord and Tenant Act (68 P.S. §250.101 et seq.).

Important Disclosures Before Completing
- There is no statutory cap on application or screening fees in Pennsylvania. The fee amount is disclosed above and is non-refundable regardless of approval decision.
- A consumer report (credit report, background check, eviction history, criminal history) may be obtained.
- You have the right under FCRA to a copy of any consumer report obtained and to dispute inaccurate information.
- This application does not create a tenancy or guarantee approval. All decisions are based on objective, consistently applied screening criteria.
- Criminal history screening must comply with HUD fair housing guidance (no blanket bans; individualized assessment).
- The security deposit is limited by statute to two (2) months' rent in the first year and one (1) month's rent thereafter (68 P.S. §250.511a).

All user-supplied values are `[[Token Name]]` placeholders., -

1. Applicant Personal and Contact Information

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

Date of Birth: [[Date of Birth]]

Social Security Number (for screening only): [[SSN, last 4 shown here; full SSN required on signed authorization]]

Driver's License / Government ID: [[State]] [[ID Number]]

Current Phone: [[Applicant Phone Number]]

Email Address: [[Applicant Email Address]]

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

How long at current address: [[Duration]]

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

Reason for moving: [[Reason]], -

2. Co-Applicant or Additional Occupant Information (if any)

Co-Applicant Full Name: [[Co-Applicant Full Name or "N/A"]]

Relationship to Applicant: [[Relationship]]

Date of Birth: [[Date of Birth]]

Phone / Email: [[Phone and Email]]

Will this person be a lease signer? [[Yes / No]]

Additional Occupants (names, ages, relationship): [[List Additional Occupants or "None"]], -

3. Residency History (Last 3 Years or 2 Prior Residences)

Previous Address 1: [[Street, City, State, ZIP]]

Dates of Occupancy: [[From Date, To Date]]

Landlord / Manager Name & Phone: [[Name and Phone]]

Monthly Rent: $[[Prior Rent Amount]]

Reason for Leaving: [[Reason]]

Previous Address 2 (if applicable): [[Street, City, State, ZIP]]

Dates of Occupancy: [[From Date, To Date]]

Landlord / Manager Name & Phone: [[Name and Phone]]

Monthly Rent: $[[Prior Rent Amount]]

Reason for Leaving: [[Reason]]

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

Have you ever broken a lease or been sued by a landlord? [[Yes / No, If yes, explain: [[Explanation]]]], -

4. Employment and Income Information

Current Employer: [[Employer Name]]

Position / Job Title: [[Job Title]]

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

Employer Address: [[Employer Address]]

Dates of Employment: [[Start Date, Present or End Date]]

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

Other Income Sources (SSI, child support, alimony, pensions, etc.): [[Source and Amount or "None"]]

If self-employed: Business name and nature: [[Details]]; Provide tax returns or 1099s for last 2 years upon request.

Previous Employer (if current < 2 years): [[Employer Name, Position, Dates, Income]], -

5. Financial and Credit Information

Bank Name(s) and Account Type: [[Bank Name(s), Checking / Savings]]

Approximate Liquid Assets (optional but helpful): $[[Approximate Savings / Investments]]

Credit Score Range (self-reported, optional): [[e.g., 650-700 / Above 700 / Below 600 / Unknown]]

Have you ever filed for bankruptcy? [[Yes, Chapter and Year / No]]

Have you ever had a judgment, lien, or collection account related to housing? [[Yes / No, Details]], -

6. Vehicle and Parking Information

Vehicles to be parked at property (make/model/year/license): [[Vehicle 1]] [[Vehicle 2 or "None"]]

Do you require assigned or off-street parking? [[Yes, number of spaces / No]], -

7. Pets and Assistance Animals

Pets (dogs, cats, other): [[Number, Type, Breed, Weight, Age or "None"]]

Service or Emotional Support Animal (if any): [[Type and documentation will be requested separately]]

Pet Deposit or Fee (if applicable and permitted): $[[Pet Deposit or Monthly Pet Rent or "N/A"]], -

8. Emergency Contact and References

Emergency Contact Name: [[Emergency Contact Full Name]]

Relationship: [[Relationship]]

Phone: [[Phone Number]]

Address: [[Address]]

Personal Reference 1 (non-relative): [[Name]] Phone: [[Phone]] Relationship: [[Relationship]]

Personal Reference 2 (non-relative): [[Name]] Phone: [[Phone]] Relationship: [[Relationship]], -

9. Application / Screening Fee Disclosure and Authorization

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

This fee covers the cost of obtaining consumer reports, background checks, credit reports, eviction history, and related screening. The fee is non-refundable whether the application is approved, denied, or withdrawn.

By signing below, Applicant authorizes the Landlord / Property Manager and its screening agents to obtain consumer reports, credit reports, background checks (including criminal and eviction history), employment and income verification, and landlord references. This authorization is valid for the purpose of evaluating this application and is given pursuant to the Fair Credit Reporting Act.

Applicant understands that a copy of any consumer report will be provided upon request, and Applicant has the right to dispute the accuracy of information in the report.

Screening Criteria Summary (objective criteria used by this landlord):
- Income: Minimum [[e.g., 3x monthly rent]] gross monthly income
- Credit: Minimum score or no recent housing-related collections/evictions (case-by-case review)
- Rental history: Positive references preferred; prior evictions or lease violations may result in denial
- Criminal history: Individualized assessment per HUD guidance; no automatic blanket exclusion
- Other: [[Additional criteria, e.g., no more than 2 occupants per bedroom, valid ID, etc.]], -

10. Fair Housing and Nondiscrimination Notice

This landlord complies with the federal Fair Housing Act, the Pennsylvania Human Relations Act (PHRA), and all applicable local fair housing laws.

We do not discriminate on the basis of race, color, religion, sex, national origin, familial status, disability, age, or any other protected class under federal, state, or local law.

If you believe you have been discriminated against, you may contact the Pennsylvania Human Relations Commission, the U.S. Department of Housing and Urban Development (HUD), or an attorney., -

11. Criminal History Screening Acknowledgment (HUD Guidance)

Landlord conducts individualized assessments of criminal history. A criminal record will not automatically disqualify an applicant. Factors considered include the nature and severity of the offense, time elapsed, evidence of rehabilitation, and relationship to tenancy safety or property.

Applicant may provide mitigating information or evidence of rehabilitation with this application., -

12. Applicant Certification and Signature

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 the application or termination of any tenancy later created.

I have read and understand the fee disclosure, screening criteria summary, and fair housing notice above.

I authorize verification of all information provided, including consumer reports and background checks.

Applicant Signature: ________________________________ Date: [[Date]]

Printed Name: [[Applicant Full Name]]

Co-Applicant Signature (if applicable): ________________________________ Date: [[Date]]

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

13. Landlord / Agent Use Only (Do Not Complete by Applicant)

Application Received Date/Time: [[Date/Time]]

Fee Received: $[[Amount]] Method: [[Cash / Check # / Online / Other]]

Screening Ordered Date: [[Date]]

Report(s) Received: [[Date(s)]]

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

Reason for Denial (if applicable, must be specific and consistent with criteria): [[Specific Reason(s) or "N/A"]]

Adverse Action Notice Provided (if denied): [[Date and Method, FCRA requires notice]]

Notes: [[Internal Notes]], -

*Sample template for Pennsylvania, not legal advice. This application form is designed for compliance with FCRA, the Fair Housing Act, the Pennsylvania Human Relations Act, and the Pennsylvania Landlord-Tenant Act (68 P.S. §250.101 et seq.). There is no statutory cap on application fees, but the amount and non-refundable nature must be disclosed. Security deposits are limited to 2 months' rent the first year and 1 month thereafter (68 P.S. §250.511a). Criminal history screening must follow individualized assessment per HUD guidance. All [[Token Name]] fields are for user-supplied information. Verify current requirements and consult counsel before use. References current as of 2026-06.*