The Redevelopment Authority of Cumberland County is evaluating the below named applicant's eligibility for our home ownership program and we need to evaluate the applicant's rental payment history and care of the rental property. Please complete this form and return it in the enclosed postage paid envelope. The Redevelopment Authority appreciates your assistance in helping us evaluate the applicant's credit history.

Applicant's Name and Address: ____________________________________________

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I would like the requested information regarding my rental history to be furnished to the Redevelopment Authority of Cumberland County as soon as possible.

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Date of initial occupancy: ________ Current rent amount: __________

Rent due date: _______ Is rent subsidized? ____________

If subsidized, amount: $__________ Who pays subsidy? ____________

Lease expiration date: ___________

Does rent include utilities or allowances? ____ Amount of utilities or allowances

included in rent:___________

List names and approximate ages of all persons occupying the property:

Rental History During the Last 12 Months: Current Status of Rent:

(please check one)

___ Always pays by the due date ___ Current ___Behind

___ Pays within 1-10 days of due date Amount behind: $_____________

___ Pays over 30 days late Date last paid: ________________

___ Generally stays behind schedule Next due date: ________________

Does Tenant Maintain Property in Good Repair _____Yes ____No

If "No" is checked, please explain below:

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Landlord Signature                                                                                 date completed