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Form #42 : APPLICANT SCREENING CHARGE RECEIPT

Required entries are indicated by blue icons or *

Applicant* (required)

Address

Unit #

City

State

Zip Code

Amount of Charge

"Applicant Screening Charge" means any nonrefundable payment of money charged by an Owner/Agent of a prospective Tenant prior to entering into a rental agreement with that applicant for a residential dwelling unit, the purpose of which payment is to process an application for a residential dwelling unit.

I acknowledge the receipt of an applicant screening charge.

Please Note: Signature field must be filled in and signed after printing.


Owner/Agent Signature:				Date:

Owner/Agent

Address

City

State

Zip

Telephone

Form #42 : APPLICANT SCREENING CHARGE RECEIPT

Rev.4/16

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