Indiana Residential Rental Application and Screening Packet

Indiana Residential Rental Application and Screening Packet

Use one packet per adult applicant. Deliver written criteria before collecting money or ordering a report.

Privacy rule: Do not place sensitive identifiers or financial-account numbers in this packet. Use a separately approved secure identity channel with access controls and a retention schedule.

Indiana Fair-Housing Screening Module

Indiana civil-rights guidance identifies race, color, religion, sex, disability, national origin, ancestry, and familial status as protected in housing. Housing decisions must rest on legitimate, consistently applied criteria rather than protected characteristics. Ind. Code § 22-9.5-5-1.

• Application contains no prohibited protected-status inquiry: ☐ Confirmed
• Criteria reviewed for ancestry discrimination: ☐ Yes
• Fee/purpose/refundability after current state and local review: [________________________________]

1. Property and Housing Provider

• Property address/unit: [________________________________]
• Monthly rent/proposed move-in/term: [________________________________]
• Housing provider/agent and notice address: [________________________________]
• Completed application received: [__/__/____] at [____] ☐ a.m. ☐ p.m.

2. Written Screening Criteria

Apply criteria consistently and document the verified fact supporting each decision.

3. Applicant Information

• Full legal name/name used for references: [________________________________]
• Email/telephone: [________________________________]
• Current address and time there: [________________________________]
• Requested move-in date: [__/__/____]
• Other proposed occupants and relationship: [________________________________]
• Animals: [________________________________]
• Confidential assistance-animal process requested: ☐ Yes ☐ No

Do not ask for protected-status, diagnosis, or disability details here.

4. Residence and Income History

5. Applicant Statements and Consumer-Report Authorization

• ☐ Information is complete and accurate to the best of the applicant's knowledge.
• ☐ Applicant received criteria and fee disclosure before payment.
• ☐ Applicant received the privacy/retention notice.
• ☐ Applicant understands this is not a lease or promise of approval.

I give written instructions authorizing [HOUSING PROVIDER/AGENT] and [CONSUMER REPORTING AGENCY] to obtain and use the checked reports solely for this rental application and lawful account review. 15 U.S.C. § 1681b(a)(2).

• Agency/address/telephone: [________________________________]
• Reports: ☐ Credit ☐ Rental history ☐ Eviction records ☐ Criminal records ☐ Other: [________]
• Authorization expires: [__/__/____]

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

6. Receipt and Decision Record

• Amount/character: $[________] ☐ No payment ☐ Application fee ☐ Refundable deposit
• Criteria applied exactly as disclosed: ☐ Yes
• Decision: ☐ Approved ☐ Conditional approval ☐ Denied ☐ Withdrawn
• Criterion and verified fact: [________________________________]
• Consumer report affected decision: ☐ Yes ☐ No
• Decision maker/date: [________________________________]

7. Adverse-Action Notice

Applicant/property/action/specific reason: [________________________________]

If a consumer report affected the action, identify the agency, address, telephone, score and required score factors if used. The agency did not make the decision. The applicant may request a free report within 60 days and dispute inaccurate or incomplete information. 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)
• Ind. Code title 22 — Indiana General Assembly — https://iga.in.gov/laws/2025/ic/titles/22#22-9.5-5-1
• Indiana Civil Rights Commission — current housing guidance — https://www.in.gov/icrc/enforcement/housing/