Information Disclosure Consent

I (Participant Name) __________________________________________________ DOB: __________________ hereby

authorize People Assisting the Homeless (PATH) to release information pertaining to the Housing Location Tenant
Screening Services. Tenant Screening information collected by PATH, i ncluding credit/economic, criminal, sex
offender, employment, tenancy history and other information related to my background check may be disclosed
to the following entities as part of Housing Location Risk Mitigation Program, and for auditing purposes :

Property Owners/Landlords
Los Angeles Homeless Services Authority
Veterans Administration
Los Angeles County Department of Mental Health
Los Angeles County Department of Health Services
Public Housing Authorities
Referring Agency Provider Name and Contact: _________________________________________
__ _____ _ __ _ __ _ __ _ __ _ __ __ _ ___ _ _ __ _ __ _ __ _ __

Other: ________________________________________________________

The disclosure of information/records authorized herein is required for participant linkage to assistance and
services. Release of information to selected entities is valid for one year from date of signature.
This authorization provides for information disclosure between the individual listed above and the entities indicated
above. By providing consent, I hereby release PATH (People Assisting The Homeless), and its officers, employees, affiliates
and partners from any claims, damages or liabilities of any kind, that may directly or indirectly result from the use,
disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to
me.

____________________________________
Referring Staff Member Agency __ ____ ___ ___ __ __ ____ ___ ___ ___ _____ ____ ____ ___ ___ ___ _____ ____ _

______________________________________
Staff Member Name __ ____ ___ ___ ___ _____ ____

______________________________________
Staff Member Phone ____________________
Participant ID #
_ ___ ___ ___ _____ __

_____________________________
__ ____ ___ ___ ___ _____ ____ ____ ___ ___ __

______________________________________
Staff Member Email Participant Name

____________________________________ _____________________________
Staff Member Signature Date Participant Signature Date

Completed forms and any questions may be sent to LeaseUpLA@ePath.org

Housing Partnerships Program 1 of 1

Revised 4/2019
 APPLICATION TO RENT
(All sections must be completed) Individual applications required from each occupant 18 years of age or older.
Last name First Name Middle Name Social Security Number or ITIN

Other names used in the last 10 years Work phone number Home phone number
( ) ( )
Date of birth E-mail Address Mobile/Cell phone number
( )
Photo ID/Type Number Issuing government Exp. Date Other ID

State Zip
1. Present Address City

Date in Date out Owner/Agent Name Owner/Agent Phone Number

Reason for Moving Current Rent

$ /Month
State Zip
2. Previous Address City

Date in Date out Owner/Agent Name Owner/Agent Phone Number

Reason for Moving

Previous Address City State Zip

3.
Date in Date out Owner/Agent Name Owner/Agent Phone Number

Reason for Moving

Proposed Name Name

Occupants:
List all in Name Name
addition to
yourself
Name Name

Will you have Describe Will you have a waterbed Describe

pets?
Yes ✓ No Yes ✓ No
How did you hear about this rental?

I✓
! am ! am not a member of the Armed Forces (including the National Guard and Reserves)
Present occupation or source of income Employer Name
A.
Dates of Employment Supervisor’s phone number Employer Address How Long?
( )
Name of your supervisor City, State, Zip

Present occupation or source of income Employer Name

B.
Dates of Employment Supervisor’s phone number Employer Address How Long?
( )
Name of your supervisor City, State, Zip

Current Gross Income Per: Check one

Please list ALL of your financial obligations below
$ ! Week ✓
! Month ! Year
Name of your bank Branch or address Account Number

Form Provided by Contemporary Information Corp.

For Membership Information Call (800) 288-4757
or Visit our Website at www.cicreports.com
Form 157.1 © 2009-2015 (Revised 03/15) Revised 4/2019
 Name of Creditor Address Phone Number Monthly Payment Amt.

( )

( )

( )

( )

( )

( )
In case of emergency, notify: Address: Street, City, State, Zip Relationship Phone
1.

2.

Length of
Personal References: Address: Street, City, State, Zip Occupation Phone
Acquaintance
1.

2.

Automobile: Make: ____________________ Model: ____________________ Year: __________ License #: _________________

Automobile: Make: ____________________ Model: ____________________ Year: __________ License #: _________________
Other motor vehicles: _______________________________________________________________________________________
Have you ever filed for bankruptcy? " Yes "
✓ No Have you ever been evicted or asked to move? "
✓ Yes " No

Applicant represents that all the above statements are true and correct and hereby authorizes verification of the above items including, but
not limited to, the obtaining of a credit report and agrees to furnish additional credit references upon request. Applicant consents to allow
Owner/Agent to disclose tenancy information to previous or subsequent Owner/Agents.

Owner/Agent will require payment of $__________ , which is to be used to screen Applicant with respect to credit history and other background
information. The amount charged is itemized as follows:
1. Actual cost of credit report, unlawful detainer (eviction) search, and/or other screening reports $__________
2. Cost to obtain, process and verify screening information (may include staff time and other soft costs) $__________
3. Total fee charged $__________
The undersigned is applying to rent the premises designated as:
Apt # __________ Located at ______________________________________________________________________________________________
The rent for which is $ __________ per __________. Upon approval of this application, and execution of a rental/lease agreement, the applicant
shall pay all sums due, including required security deposit of $__________, before occupancy.

_____________________ ________________________________________________________________
Date Applicant (signature required)
OUR CODE FOR EQUAL HOUSING OPPORTUNITY
We support the spirit and intent of all local, state, and federal fair housing laws for all residents without regard to race, color, sex, religion, mental or
physical disability, age, marital status, sexual orientation, family status, or national origin.
We reaffirm the belief that equal opportunity can best be accomplished through effective leadership, education, and the mutual cooperation of owners,
managers, and the public.
Therefore, we agree to abide by the following provisions of this Code for Equal Housing Opportunity:
• We agree that in the rental, lease, sale, purchase, or exchange of real property, owners and their employees have the responsibility to offer
housing accommodations to all persons on an equal basis.
• We agree to set and implement fair and reasonable housing rules and guidelines and will provide equal and consistent services throughout
our residents’ tenancy.
• We agree that we have no right or responsibility to volunteer information regarding the racial, creed, or ethnic composition of any
neighborhood, and we do not engage in any behavior or action that would result in “steering.”
• We agree not to print, display, or circulate any statement or advertisement that indicates any preference, limitations, or discrimination in the
rental or sale of housing.

Form Provided by Contemporary Information Corp.

For Membership Information Call (800) 288-4757
or Visit our Website at www.cicreports.com
Form 157.1 © 2009-2015 (Revised 03/15) Revised 4/2019