Sample Rental Application Fee Disclosure Statement

Applicant’s Address:

Rental Application Fee: $50.00

As part of your rental application, a rental application fee may be collected to facilitate a screening and background check. This Rental Application Fee Disclosure Statement (“Disclosure Statement”) outlines certain information related to your rental application fee.

You are notified of and acknowledge and agree to the following:

  1. Prior to paying the rental application fee, you have received a copy of this Disclosure Statement and all referenced exhibits.
  2. Your application will be judged based on the criteria attached as Exhibit A (the “Screening Criteria”).
  3. We have disclosed the rental application fee to you, including in any advertisement and postings related to the available rental unit and the actual rental application fee charged is consistent with those disclosures.
  4. In the event the rental unit that you applied for is not available, you agree that we may place you on our waiting list.
  5. The screening process for our rental units includes a review of the referenced Criteria, including as may be completed through a third party. The name and contact information for the person, screening agency, or third party used is listed below:
    Apply Connect
    42913 Capital Dr., Unit 101
    Lancaster, CA 93535
    800.288.4757 Option 7
    Lloyd Real Estate, LLC
    PO Box 291
    Comstock Park, MI 49321
    (616) 558-6715
  6. The rental application fee listed above consists of the below charges. Applicant acknowledges that we may incur such costs which are reasonable and necessary to complete the screening and background check process.
    > Apply Connect (including Social Security Number Trace, Nationwide Criminal Database Search, Nationwide Eviction Database Search, Michigan ICHAT Search, Applicant Credit Report with FICO Score)……$29.50
    > File Processing – Landlord Reference Check, Cosigner Agreement Form/Employment Verification conducted by Lloyd Real Estate, LLC……$20.50
    > Total Application Fee……$50.00
  7. In the event you are not offered the rental unit applied for, you will receive a notice explaining the reason or reasons that the rental unit was not offered to you along with a list of resources that you may use to assist with future application processes. Any correspondence related to this Disclosure Statement will be sent to the above Applicant’s Address by US Mail.

“Within thirty (30) days of receipt of a denial, the applicant may, if a person believes the City of Grand Rapids rental application fee ordinance has been violated, complete and file a complaint form with the City of Grand Rapids Code Compliance Department, 1120 Monroe Avenue NW, Grand Rapids, Michigan 49503.”
Applicant’s Acknowledgement (Applicant’s Initials)

Click here to view a copy of screening criteria

Certification of Accuracy

The following Applicant has reviewed the information above and certifies that the information provided is true and accurate.

Applicant’s Signature