Nebraska Residential Rental Application and Screening Packet

Nebraska 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.

Nebraska Fair-Housing Screening Module

Nebraska prohibits discriminatory housing decisions, terms, statements, advertisements, and protected-status inquiries or records because of race, color, religion, national origin, disability, familial status, sex, or military or veteran status. Neb. Rev. Stat. § 20-318, as amended in 2025.

• Application contains no prohibited protected-status inquiry or record: ☐ Confirmed
• Criteria reviewed for military and veteran status: ☐ 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

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)
• Neb. Rev. Stat. § 20-318 — https://nebraskalegislature.gov/laws/statutes.php?statute=20-318