New York Residential Rental Application and Screening Packet

New York 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: [________________________________]

New York Background/Credit-Check Fee Module

No application-processing, review, or acceptance fee may be charged. A background- and credit-check reimbursement may not exceed the lesser of actual cost or $20.

• Applicant provided a background or credit check completed within the past 30 days: ☐ Yes ☐ No
• If yes, fee waived: ☐ Yes
• Actual combined check cost: $[________]
• Fee charged (lesser of actual cost or $20): $[________]
• Copy of each check delivered to applicant: ☐ Yes
• Vendor receipt/invoice delivered to applicant: ☐ Yes

This module does not address statutory exceptions for specified senior facilities or cooperative-housing applicants. Obtain legal review before using it in those settings. N.Y. Real Prop. Law § 238-a(1).

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.

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 state and local protected classes 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 ☐ Screening/application fee ☐ Refundable application deposit
• Payment method/reference (no full account number): [________________________________]
• Vendor/out-of-pocket component: $[________]
• Housing-provider processing component, if lawful: $[________]
• Refund due: $[________] by [__/__/____]
• Receipt/itemization delivered by: ☐ Paper ☐ Email
• 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: ☐ No ☐ Yes: [____]
• Required score-factor disclosures attached, if applicable: ☐ Yes ☐ Not applicable

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)
• N.Y. Real Prop. Law § 238-a — https://www.nysenate.gov/legislation/laws/RPP/238-A