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Complete Your Custom ORHA Rental Form

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S3 : APPLICANT SCREENING CHARGE RECEIPT

Required entries are indicated by blue icons or *

Applicant Name(s)* (required)

Property Address* (required)

Unit #

Applicant Mailing Address

City

State

Zip Code

Amount of Charge:

0.00

"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. The purpose of this payment is to process an Application for a Rental 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

S3 : APPLICANT SCREENING CHARGE RECEIPT

Rev.7/21

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