Fax/office:

574-831-6170
-Or574-202-6649

P.O. Box 51
New Paris, IN 46553
-Or19097 CR 46 New Paris, IN

Please submit a non-refundable application fee in the amount of $25 payable to Assurance Property Management, LLC.
____________________________________________________________________________
Address(es) Applying for
____________________________
_____________________________
______________________________
Name
Social Security Number
Drivers License Number
____________________________
_____________________________
______________________________
(Spouse) Name
(Spouse) Social Security Number
(Spouse) Drivers License Number
Phone #(s): Home_______________________ Work:________________________ Cell:___________________________
Date of Birth:____________ Number of Children:________
Number of Pets:_______(Type)___________________
Does anyone living in your household smoke indoors? Yes
No (Please Circle)
Current address:___________________________________ Number of Months at Current Address:_________________
Current Landlords Name:___________________________ Phone #:__________________________________________
Previous Address:__________________________________ Number of Months at Previous Address:________________
Previous Landlords Name:________________________
Phone #:__________________________________________
Current Employer:_______________________________ Phone #:__________________________________________
Length of Employment:________ Gross Weekly Income (before tax):__________________________________________
Previous Employer:______________________________
Phone #:__________________________________________
Spouses Employer:______________________________
Phone #:__________________________________________
Monthly Debt(s):_______________ _______________ _______________ _______________ _______________
Vehicle(s)
Credit Card(s)
Furniture
Child Support
Other
Have you filed bankruptcy in the last 10 years?:__________________ (If yes, please explain on back)
Have you been more than 30 days late on any payments in the last year?:______________ When?:_________________
Have you or your spouse ever been evicted from a rental property?:__________________ When?:_________________
Before Assurance Property Management, L.L.C. will rent any premises, the applicant and/or co-applicant must provide
one form of government issued photo I.D. for copying purposes.
RELEASE
By signing this agreement, I/we hereby confirm that the above information is true and correct. In addition, I/we hereby permit
Assurance Property Management, LLC. to run a credit report/check with a national Credit Bureau to determine my/our credit
worthiness. I/We understand that we are not entering into a lease, but are providing this information in order to assist Assurance
Property Management, LLC. in evaluating our credit worthiness. I/We may revoke this at any time.
___________________________________________
Signature

____________________________________________
(Spouse) Signature

----If Married---___________________________________________
____________________________________________
Printed Name
(Spouse) Printed Name
Thank you for choosing Assurance Property Management, LLC. Rest assured; were working with you!
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*FOR OFFICE USE ONLY*
Paid application fee:
Potential tenant would like to be moved in by:___________________________________________
Cash Check/M.O. - Credit/Debit
Notes:______________________________________________________________________