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Please Note:

When using the Portland Application for Rent (Form S1PD), you must also choose one of two Portland Screening Guidelines Forms to provide to all Applicants. You may either choose "Landlord Choice" (Form S4PD) or "Low Barrier" (Form S5PD) depending on your preference/situation.

The Portland Screening Guidelines form(s) must be purchased and filled in separately as they are not included with the Portland Application to Rent form. Be sure to have each Applicant Review the Guidelines and confirm receipt of the disclosure by signing the bottom of the form. Make a copy for each of the Applicant(s) and keep the originals on file with the Application


FormS1PD : PORTLAND APPLICATION TO RENT

 

Required entries are indicated by blue icons or *


Date Received
Time Received
 

OWNER/AGENT TO COMPLETE UPON RECEIPT OF APPLICATION

  of units available (of the type and in the area) that will be available for rent in the near future by this owner.
 of applications previously accepted and remaining under consideration for those units.
(If left blank, at least one unit is available and no previously accepted applications currently under consideration have been accepted.)

 Examined picture identification?
 
Type of identification?
 

Owner/Agent uses the following Screening Criteria:

 Finacially Responsible Applicant? 

Applicants may include Supplemental Evidence for consideration, in order to mitigate potentially negative screening results. Refer to Screening Disclosures below and the Application Screening Guidelines and Information Release form provided by Owner/Agent for a recitation of criteria for residency, the evaluation process, and the amount of a screening charge, if any.

Applicants are strongly encouraged to review the following information from the Portland Housing Bureau (PHB):

1) PHB Statement of Applicant Rights & Responsibilities:
https://www.portland.gov/sites/default/files/2020-01/notice-30.01.086.c.3.c-application-and-screening-rights-and-responsibilities.pdf
2) City Notice to Applicants for requesting a Reasonable Accommodation or Modification:
https://www.portland.gov/sites/default/files/2020-01/notice-30.01.086.c.3.b-modification-or-accommodation.pdf.


RENT, DEPOSIT AND FEE DISCLOSURE

If checked, the above-referenced unit is ADA accessible as a Type A Unit in accordance with the Oregon Structural Building Code and ICC A117.1, providing accessibility for wheelchair users throughout the unit.
Monthly Rent:
 
Security Deposit:
 
Other Deposit:
 

DEPOSITS MAY INCREASE IF APPLICANT IS UNABLE TO MEET ONE OR MORE OF OWNER/AGENTS SCREENING CRITERIA.


If checked, Renter’s Insurance is required
– Tenant is required to maintain minimum of $100,000 liability coverage and list Owner/Agent as Interested Party. If Tenant(s) combined household income falls at or below 50% of the median for the area, Renter’s Insurance may not be required. Owner/Agent is also responsible to maintain their own insurance policy and may not “self insure” if Renter’s Insurance is to be required. Owner/Agent must provide proof of property insurance to Tenant upon request.

Owner/Agent may charge the following:
  • Late payment of rent charge of
     
  • Smoke alarm and carbon monoxide alarm tampering fee of $250.
  • Dishonored check fee of $35 plus amount charged by bank.
  • Early termination of lease fee not to exceed 1-1/2 times the monthly rent, or actual damages at the option of Owner/Agent.
  • Owner/Agent may charge the following Noncompliance Fees after first giving a Written Warning Notice of initial violation if noncompliance occurs within one year: $50 fee for 2nd violation, and $50 plus 5% of current Rent for each subsequent violation.
    1. Failure to clean up animal waste, garbage, rubbish or other waste.
    2. Parking violation or other improper use of vehicle.
  • Owner/Agent may charge a Fee for keeping on the premises an unauthorized pet capable of causing damage. Fee may be assessed for repeat violations that occur as early as 48 hours after the effective date of Written Warning Notice, and for each subsequent violation within one year of issuance of Written Warning. Fee not to exceed $250 per violation.
  • Owner/Agent may charge a Fee for smoking/vaping in a clearly designated non-smoking/vaping unit or area of the premises. Fee may be assessed for repeat violations that occur as early as 24 hours after the effective date of a Written Warning Notice, and for each subsequent violation within one year of issuance of Written Warning. Fee not to exceed $250 per violation.

PERSONAL INFORMATION

The Portland Housing Bureau requires Applicants be allowed an opportunity to disclose a mobility or other disability. This is voluntary.

 “Mobility Disabled,” with respect to a person, means a Disability that causes an ongoing limitation of independent, purposeful, physical movement of the body or one or more extremities and requires a modifiable living space because of, but not limited to, the need for an assistive mobility device.
(First Middle Last)
Telephone:
 (
)
-
Cellular Number:
 (
)
-

1)
 
Since:
 
Why are you moving?
 
Rent Amount:
 
Telephone:
 (
)
-

Telephone:
 (
)
-

Telephone:
 (
)
-

Have you ever:
 
Been Evicted?

Been Sued by Landlord?

Filed Bankruptcy?

Been convicted, or plead guilty or no contest, to a crime?

If yes to any of these, please explain:
 

Please list all household animals.
 

 Animal 1

Ever injured anyone or damaged anything?

 Animal 2

Ever injured anyone or damaged anything?
 

OUTSTANDING DEBTS - If you are a non-financially responsible Applicant, do not fill out thhis section.

Please list below all outstanding past due payment obligations and/or collections accounts.

EMPLOYMENT/INCOME - If you are a non-financially responsible Applicant, do not fill out thhis section.

 
Telephone: 
 (
)
-

Telephone:
 (
)
-

Telephone:
 (
)
-

Telephone:
 (
)
-

REFERENCES

1. Relative:
Telephone:
 (
)
-
2. Emergency Contact:
Telephone:
 (
)
-
3. Personal Reference:
Telephone:
 (
)
-

PERSONAL PROPERTY

Automobile #1:

Automobile #2:

Other: (Vehicles/Boats)

Do you own the following:
 
Trampoline?

Water-filled furniture?

Fish Tank or Aquarium?

MEMBERS OF HOUSEHOLD

For purposes of identification only, please list names and either ages or dates of birth of other persons to occupy unit:

NONDISCRIMINATION POLICY Equal Housing Opportunity

  • We do business in accordance with Fair Housing Law.
  • We do not discriminate among Applicants based on membership in a protected class including, race, color, religion, sex, sexual orientation, national origin, disability, marital status, familial status, source of income, or any other protected class as defined in any federal, state or local law.

APPLICANT SCREENING CHARGE DISCLOSURES

  1. Owner/Agent may obtain a credit report, or a Tenant Screening Report which generally consists of:
    • a) Credit history including credit report;
    • b) Public records, including but not limited to judgments, liens, evictions and status of collection accounts;
    • c) Current obligations and credit ratings; and/or
    • d) Criminal records or other information verification.
  2. Owner/Agent is requiring payment of an
    Applicant Screening Charge
     
    none of which is refundable unless the Owner/Agent does not screen the Applicant. This Application is valid for up to 60 days from date of receipt by Owner/Agent.
  3. Any charges imposed upon Owner/Agent by a Homeowner’s or Condominium Association for anyone who moves into or out of a unit within the association, may be passed through to the Tenant(s) for payment as allowed by law.
    Current Fee is
     
  4. If the mail receptacle associated with the Dwelling Unit is a locking type, Tenant(s) are solely responsible for the Fees charged by the Postmaster for the re-keying of the box should a key not be provided by the Owner/Agent, or if the mail box has not been re-keyed between tenancies.
If an Application or a group of Applications is/are approved, Applicant(s) will have
 
business days to either execute a Rental Agreement, pay all moneys due, and take possession of the unit if the unit is rent-ready.
If the unit is not rent-ready, Applicant must submit the security deposit in full within the above-referenced time frame, and sign a Deposit to Hold Agreement in order to secure their right to rent the unit. Failure to follow through within the time frame indicated will be deemed a refusal of the unit, and Applicant(s) will lose their place in line. Rent accrues from the date the property is ready or the date of approval, whichever comes last, regardless of when Applicant/Tenant moves into the Dwelling Unit. Applications are valid for 60 days from the date of submission for any properties owned or managed by Owner/Agent.
In the event an Application is denied and subsequently approved upon appeal, the Application is valid for a period of three months from the Date of Approval. If the unit applied for has been rented to another, Applicant will be contacted by Owner/Agent in the event another similar unit becomes available within that time frame. Contact will be made by email, phone or certified mail to offer the unit with a deadline of 48 hours for Applicant to respond and declare their intent to rent the unit.
Upon acceptance of the substitute unit, Applicant(s) will have
 
 business days to either execute a Rental Agreement, pay all moneys due, and take possession of the unit, or submit the Security Deposit in full and sign a Deposit to Hold Agreement. Failure to follow through with these requirements will be deemed a refusal of the unit, and Applicant(s) will lose their place in line.

Owner/Agent may refuse to accept an Application under the following circumstances:

  1. Application is incomplete.
  2. Applicant fails to provide information to confirm identity or income.
  3. Applicant has intentionally withheld or misrepresented required information.
  4. Applicant has verifiable repeated violations of the Rental Agreement with the same Landlord. Most recent violation must have occurred within the past 365 days from the date the Application is submitted, and past Landlord must provide copies of the violation notices.

I certify the above information is correct and complete and hereby authorize the Owner/Agent to make any inquiries the Owner/Agent feels necessary to evaluate my tenancy and credit standing (including, but not limited to credit reports). If Owner/Agent is requiring payment of an Applicant Screening Charge, I acknowledge receiving a copy of and/or reading Owner/Agent’s Screening Guidelines. I understand that I have the right to dispute the accuracy of any information provided to the Owner/Agent by a screening service or credit reporting agency.

No marijuana, medical or otherwise, may be grown, stored or consumed on the premises without the prior written consent of Owner/Agent.

 

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

Applicant    Date 
 

The following forms are required to be included with this form by the City of Portland, OR

 
Portland Housing Bureau Letterhead

Right to Request a Modification or Accommodation Notice

Required Under Portland City Code Title 30.01.086.C.3.B

For residentil rental units within Portlnd city limits, a landlord is required to include this notice with application forms for the rental of a dwelling unit.

State and federal laws, including the Fair Housing Act, make it illegal for housing providers to refuse to make reasonable accommodations and reasonable modifications for individuals with disabilities. All persons with a disability have a right to request and be provided a reasonable accommodation or modification at any time, from application through to termination/eviction.

Some examples of reasonable accommodations include:

  • Assigning an accessible parking space
  • Transferring a tenant to a ground-floor unit
  • Changing the rent payment schedule to accommodate when an individual receives public benefits
  • Allowing an applicant to submit a housing application via a different means
  • Allowing an assistance animal in a "no pets" building. More information about assistance animals is available here:
    https://www.hud.gov/program_offices/fair_housing_equal_opp/assistance_animals

Some examples of reasonable modification include:

  • Adding a grab bar to a tenant's bathroom
  • Installing visual smoke alarm systems
  • Installing a ramp to the front door

Under fair housing laws, a person with a disability is someone:

  • With a physical or mental impairment that substantially limits one or more major life activities of the individual;
  • With a record of having a physical or mental impairment that substantially limits one or more major life activities of the individual;or
  • Who is regarded as having a physical or mental impairment that substantially limits one or more major life activities.

Major life activities include, but are not limited to seeing, walking, reaching, lifting, hearing, speaking, interacting with others, concentrating, learning, and caring for oneself.

Email: RentalServices@portlandoregon.gov

 
 

Portland City Code 30.01.086.C.3.B
V:2.0 VED: 3Jan2022
Page 1 of 4


 

Reasonable Accommodations

A reasonable accommodation is a change or exception to a rule, policy, practice, or service that may be necessary for a person with a disability to have an equal opportunity to use and enjoy a dwelling. This includes public use and common spaces or fulfilling their program obligations. Any change in the way things are customarily done that allows a person with a disability to enjoy housing opportunities or to meet program requirements is a reasonable accommodation.

All housing or programs are required to make reasonable accommodations. Housing providers may not require persons with disabilities to pay extra fees or deposits or any other special requirements as a condition of receiving a reasonable accommodation.

Reasonable Modifications

A reasonable modification is a structural change made to the premises in order to afford an individual with a disability full enjoyment of the premises. Reasonable modifications can include structural changes to interiors and exteriors of dwellings and to public use and common areas.

Under federal law, public housing agencies, other federally assisted housing providers, and state or local government entities are required to provide and pay for structural modifications as reasonable accommodations/modifications. For private housing, the person requesting the reasonable modification will need to cover the costs of the modification.

Verification of Disability

In response to an accommodation or modification request and only when it is necessary to verify that a person has a disability that is not known or apparent to the housing provider, they, can ask an applicant/tenant to provide documentation from a qualified third party (professional), that the applicant or tenant has a disability that results in one or more functional limitation. If the disability-related need for the requested accommodation or modification is not known or obvious, the housing provider can request documentation stating that the requested accommodation or modification is necessary because of the disability, and that it will allow the applicant/tenant access to the unit and any amenities or services included with the rental equally to other tenants.

A housing provider cannot inquire into the nature or extent of a known or apparent disability or require that an applicant or tenant release his or her medical records. Housing providers can require that the verification come from a qualified professional, but they cannot require that it be a medical doctor.

Nondiscrimination laws cover applicants and tenants with disabilities, as well as applicants and tenants and without disabilities who live or are associated with individuals with disabilities. These laws also prohibit housing providers from refusing

Email: RentalServices@portlandoregon.gov

 
 

Portland City Code 30.01.086.C.3.B
V:2.0 VED: 3Jan2022
Page 2 of 4


 

to rent to persons with disabilities, making discriminatory statements, and treating persons with disabilities less favorably than other tenants because of their disability.

Under fair housing laws, it is illegal for a housing provider to deny reasonable accommodations and reasonable modifications to individuals with disabilities. If wrongfully denied an accommodation or modification contact HUD or the Fair Housing Council of Oregon. Time limits apply to asserting any legal claims for discrimination.

Call HUD toll-free at 1-800-669-9777 or TTY 1-800-927-9275 or visit
https://www.hud.gov/program_offices/fair_housing_equal_opp/complaint-process

HUD will investigate at no cost to the complainant.

For more information about reasonable accommodations and modifications visit
www.hud.gov/program_offices/fair_housing_equal_opp/reasonable_accommodations_an d_modifications

Call the Fair Housing Council of Oregon at (503) 223-8197 ext. 2 or
http://fhco.org/index.php/report-discrimination.

Email: RentalServices@portlandoregon.gov

 
 

Portland City Code 30.01.086.C.3.B
V:2.0 VED: 3Jan2022
Page 3 of 4

 
Equal Housing Opportunity
 

If you believe you have been harassed or discriminated against because of your race, color,
national origin, religion, gender, familial status, disability, marital status, source of income,
sexual orientation including gender identity, domestic violence, type of occupation,
or age over 18 seek legal guidance regarding your rights under Fair Housing law.

 

For translation or interpretation, please call 503-823-1303
TTY at 503-823-6868 or Oregon Relay Service at 711

 

503-823-1303: Traducción e interpretación | Chuyển Ngữ hoặc Phiên Dịch | 翻译或传译
Письменныйили устный перевод | 翻訳または通訳| Traducere sau Interpretare
번역 및 통역 | Письмовий або усний переклад | Turjumida ama Fasiraadda
ةيوفشلاو ةيريرحتلا ةمجتر لا | ການແປພາສາ ຫຼື ການອະທິ ບາຍ

 

This requirement is in addition to any other rights and responsibilities set forth in the Oregon
Residential Landlord and Tenant Act under Oregon Revised Statute Chapter 90, and Portland
Landlord-Tenant Law under Portland City Code Title 30.

 

The information in this form is for educational purposes only. You should review appropriate
state statute, city code, and administrative rule as necessary. If you need legal guidance, or are
considering taking legal action, you should contact an attorney.

Email: RentalServices@portlandoregon.gov

 
 

Portland City Code 30.01.086.C.3.B
V:2.0 VED: 3Jan2022
Page 4 of 4

 
Portland Housing Bureau Letterhead

Statement of Applicant Rights and Responsibilities Notice

Required Under Portland City Code Title 30.01.086.C.3.C

Within the City of Portland, a landlord is required to include this notice with application forms for the rental of a dwelling unit.

City of Portland Applicant Rights

The City of Portland has adopted local requirements that provide additional rights and responsibilities for landlords and applicants for rental housing, beyond state law requirements, during the rental unit advertising and application process.

Applicants are strongly encouraged to submit supplemental information to offset any reasons that could lead to denial. In the event of denial, applicants have the right to appeal the decision within 30 days.

Applicants are strongly encouraged to review their rights before submitting an application.

City requirements address the following landlord tenant topics: advertising and application process screening, security deposits, depreciation schedules, rental history, notice rights, and rights for relocation assistance.

The City of Portland city code, rules, required notices and forms are listed below, and are available at: [portland.gov/rso] or by contacting the Rental Services Office at (503) 823-1303 or rentalservices@portlandoregon.gov.

Residential Rental Unit Registration

  • Portland City Code 7.02.890

Application and Screening Requirements

  • Portland City Code 30.01.086
  • Rental Housing Application and Screening Administrative Rule
  • Statement of Applicant Rights and Responsibilities Notice
  • Right to Request a Modification or Accommodation Notice
  • Rental Housing Application and Screening Minimum Income Requirement Table

Security Deposit Requirements

  • Portland City Code 30.01.087
  • Rental Housing Security Deposits Administrative Rule
  • Rental History Form
  • Notice of Rights under Portland’s Security Deposit Ordinance

Statement of Applicant Rights and Responsibilitiues
Notice 30.01.086.C.3.C (Valid through 12/31/2022)
Page 1 of 3

Equal Housing Opportunity
 

Mandatory Renter Relocation Assistance

  • Portland City Code 30.01.085
  • Mandatory Relocation Assistance Exemption Eligibility and Approval Process Administrative Rule
  • Tenant Notice of Rights and Responsibilities Associated with Portland Mandatory Relocation Assistance
  • Relocation Exemption Application Acknowledgement Letter (If applicable)

Statement of Applicant Rights and Responsibilitiues
Notice 30.01.086.C.3.C (Valid through 12/31/2022)
Page 2 of 3

 
 
Equal Housing Opportunity
 

If you believe you have been harassed or discriminated against because of your race, color,
national origin, religion, gender, familial status, disability, marital status, source of income,
sexual orientation including gender identity, domestic violence, type of occupation,
or age over 18 seek legal guidance regarding your rights under Fair Housing law.

 

For translation or interpretation, please call 503-823-1303
TTY at 503-823-6868 or Oregon Relay Service at 711

 

503-823-1303: Traducción e interpretación | Chuyển Ngữ hoặc Phiên Dịch | 翻译或传译
Письменныйили устный перевод | 翻訳または通訳| Traducere sau Interpretare
번역 및 통역 | Письмовий або усний переклад | Turjumida ama Fasiraadda
ةيوفشلاو ةيريرحتلا ةمجتر لا | ການແປພາສາ ຫຼື ການອະທິ ບາຍ

 

This requirement is in addition to any other rights and responsibilities set forth in the Oregon
Residential Landlord and Tenant Act under Oregon Revised Statute Chapter 90, and Portland
Landlord-Tenant Law under Portland City Code Title 30.

 

The information in this form is for educational purposes only. You should review appropriate
state statute, city code, and administrative rule as necessary. If you need legal guidance, or are
considering taking legal action, you should contact an attorney.

Statement of Applicant Rights and Responsibilitiues
Notice 30.01.086.C.3.C (Valid through 12/31/2022)
Page 3 of 3

 

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PO Box 20862, Keizer, OR 97307
eMail: office@oregonrentalhousing.com