Connecticut Residential Rental Application and Screening Packet

Connecticut Residential Rental Application and Screening Packet

Use this packet for one adult applicant. Give each co-applicant a separate copy. Complete and deliver the criteria and state disclosures before accepting money or ordering a report.

Privacy rule: Do not write a Social Security number, taxpayer identification number, bank-account number, payment-card number, or full government-ID number in this packet. Collect identity credentials only through a separately approved secure channel with access controls and a retention schedule.

Privacy and Secure-Handling Notice

• Designated secure identity channel: [________________________________]
• Identity data permitted through that channel: [________________________________]
• Roles authorized to access it: [________________________________]
• Encryption/access-control standard: [________________________________]
• Retention trigger and destruction date/rule: [________________________________]
• Secure destruction method: [________________________________]
• Privacy contact for access or correction requests: [________________________________]

Connecticut Screening-Fee Module

Connecticut General Statutes § 47a-4d, as amended effective upon passage by 2026 Conn. Pub. Act 26-68, § 59, bars charges for processing, reviewing, or accepting an application and bars move-in and move-out fees. A housing provider or its agent may charge only the permitted tenant-screening-report fee: a $50 statutory base plus the annual consumer-price adjustment determined by the Commissioner of Housing. Confirm the published ceiling for the application date before collecting money.

• Current adjusted maximum confirmed for application date: $[________]
• ☐ No fee charged.
• ☐ Tenant-screening-report fee charged: $[________]
• Copy of screening report, or legally sufficient access information, delivered: ☐ Yes
• Vendor receipt/invoice delivered: ☐ Yes
• Date delivered: [__/__/____]

1. Property and Housing Provider

• Property address/unit: [________________________________]
• Monthly rent: $[________]
• Proposed move-in date: [__/__/____]
• Lease term offered: [________________________________]
• Housing provider/agent: [________________________________]
• Notice address: [________________________________]
• Email/telephone: [________________________________]
• Date application became available: [__/__/____]
• Date completed application received: [__/__/____] at [____] ☐ a.m. ☐ p.m.

2. Written Screening Criteria

Complete before the applicant signs. Apply the same lawful criteria consistently.

Where the federal Fair Housing Act applies, no criterion may be applied to discriminate because of race, color, religion, sex, disability (the statute uses “handicap”), familial status, or national origin. 42 U.S.C. § 3604. Check Connecticut and local protected classes and any statutory exemption before use.

3. Applicant Information

• Full legal name: [________________________________]
• Other name used for rental-reference matching: [________________________________]
• Preferred contact method: ☐ Email ☐ Telephone ☐ Mail
• Email: [________________________________]
• Telephone: [________________________________]
• Current address: [________________________________]
• Time at current address: [________________________________]
• Requested move-in date: [__/__/____]
• Other proposed occupants and relationship to applicant: [________________________________]
• Animals: [________________________________]
• Assistance-animal accommodation requested through confidential process: ☐ Yes ☐ No

Do not ask for diagnosis or disability details on this form.

4. Residence History

Applicant authorizes the housing provider to contact the references listed above about tenancy dates, payment history, lease compliance, and property condition, subject to applicable law.

5. Income and Rent-Payment Resources

List only information relevant to the published criterion. Do not exclude a lawful source because of a protected status or source-of-income rule.

• Optional guarantor offered under the published criteria: ☐ Yes ☐ No
• Guarantor name/contact: [________________________________]

6. Applicant Statements

Applicant states that:

• ☐ The information supplied is complete and accurate to the best of the applicant's knowledge.
• ☐ The applicant received the written criteria and state disclosures before any fee or screening.
• ☐ The applicant received the housing provider's privacy/retention notice.
• ☐ The applicant understands this application is not a lease or promise of approval.
• ☐ Identity documents will be provided only through the designated secure channel.

Applicant signature: [________________________________] Date: [__/__/____]

7. Consumer-Report Authorization

I give written instructions authorizing [HOUSING PROVIDER/AGENT] and [CONSUMER REPORTING AGENCY] to obtain and use consumer report information solely to evaluate this rental application and, if a tenancy begins, for lawful account-review purposes. This authorization includes only the report types disclosed above.

This authorization relies on 15 U.S.C. § 1681b(a)(2). It does not authorize employment screening, marketing, or disclosure to unrelated persons.

• Consumer reporting agency: [________________________________]
• Address: [________________________________]
• Telephone/toll-free telephone: [________________________________]
• Report types: ☐ Credit ☐ Rental history ☐ Eviction records ☐ Criminal records ☐ Other: [________]
• Authorization expires if no report is requested by: [__/__/____]

Applicant signature: [________________________________] Date: [__/__/____]

8. Fee or Deposit Receipt

• Date received: [__/__/____]
• Amount received: $[________]
• Character: ☐ No fee ☐ Tenant-screening-report fee permitted by Conn. Gen. Stat. § 47a-4d
• Payment method/reference (no full account number): [________________________________]
• Current adjusted statutory ceiling checked: $[________]
• Screening provider and report ordered: [________________________________]
• Screening report or access information delivered by: ☐ Paper ☐ Email
• Vendor receipt/invoice delivered by: ☐ Paper ☐ Email
• Date both items delivered: [__/__/____]
• Recipient signature: [________________________________]

9. Internal Decision Record

• Application complete: ☐ Yes ☐ No
• Date screening began: [__/__/____]
• Criteria applied exactly as disclosed: ☐ Yes
• Decision: ☐ Approved ☐ Approved with lawful conditions ☐ Denied ☐ Withdrawn
• Specific criterion and verified fact supporting decision: [________________________________]
• Consumer report affected decision: ☐ Yes ☐ No
• State-required report copy/refund/notice completed: [________________________________]
• Decision maker/date: [________________________________]

Do not record protected-class information or unsupported assumptions.

10. Optional Adverse-Action Notice

• Applicant: [________________________________]
• Date: [__/__/____]
• Property: [________________________________]

Your application was:

• ☐ Denied
• ☐ Approved with an increased deposit of $[________]
• ☐ Approved with a qualified guarantor
• ☐ Approved with another condition: [________________________________]

Specific disclosed criterion and reason: [________________________________]

Consumer-report information affected this action: ☐ Yes ☐ No

If yes:

• Reporting agency: [________________________________]
• Address: [________________________________]
• Telephone/toll-free telephone: [________________________________]
• Credit score used in the decision: ☐ No ☐ Yes

If a credit score was used, complete every item required by 15 U.S.C. § 1681m(a)(2):

The reporting agency did not make this decision and cannot give the specific reasons for it. You may obtain a free copy of the report from that agency if requested within 60 days, and you may dispute inaccurate or incomplete information with the agency. 15 U.S.C. § 1681m(a).

Housing provider/agent signature: [________________________________]

Sources and References

• 15 U.S.C. § 1681b — https://uscode.house.gov/view.xhtml?req=(title:15%20section:1681b%20edition:prelim)
• 15 U.S.C. § 1681m — https://uscode.house.gov/view.xhtml?req=(title:15%20section:1681m%20edition:prelim)
• 42 U.S.C. § 3604 — https://uscode.house.gov/view.xhtml?req=(title:42%20section:3604%20edition:prelim)
• Conn. Gen. Stat. § 47a-4d — https://www.cga.ct.gov/current/pub/chap_830.htm
• 2026 Conn. Pub. Act 26-68 — https://www.cga.ct.gov/2026/act/pa/pdf/2026PA-00068-R00SB-00001-PA.pdf