A Division of First American Registy
Po Box 988
Longwood, FL 32750
Tel: 800-877-1223 / 407-331-4150
Fax: 800-788-0457/ 407-831-0457
VERIFICATION REQUEST
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize all third parties indicated on my application to furnish the information requested below to CoreLogic SafeRent. I release all third parties, their officers, agents and employees from any and all liability associated with such disclosure of the requested information.
Applicant Name: ___________________________________ Social Security Number: __________________________
Applicant Signature: ______ Date: ________________________________
TO: (COMPANY) ____________________________________________________________________________________________
Attn: __________________________________ Date: ____________ Phone #: ___________________ Fax # __________________
The applicant identified above has applied with our client: ________________________________________________________. The applicant listed you as a reference. Please fill in the "Third Party" information requested below that applies to you and return to the attention of ___ ______________________________________ via fax at (800) 788-0457. If you have any questions, please call us at (800) 877-1223 or (407) 331-4150, Ext. ________________.
EMPLOYMENT CURRENT PREVIOUS (COMPLETED BY THIRD PARTY EMPLOYER ONLY)
Does SSN match? _____ Applicant's Position: ____________________________________ Full Time: ______ Part Time: ______
Permanent: ____ Temporary: _____ Hourly Rate: $________ Hours Worked Per Week:_________ Annual Salary: $____________ Overtime:____ Amount: ________ Commission: ____ Amount: $___________ Start Date: ___________ End Date: ____________
Verified by: _______________________________________Title: ___________________________Date: ____________________
(Please print)
RESIDENCY CURRENT PREVIOUS (COMPLETED BY THIRD PARTY LANDLORD ONLY)
Does SSN match? _____Applicant's Address:______________________________________________________________________
Leaseholder Name(s): ____________________________________________Move-in Date: _________ Expiration Date: _________
Move-out Date: _______ Rent Amount: $_______ Is Current Mo. Rent Paid: _____ Is Rent Paid W/in 5 Days of Due Date: _______
Total # Late Payments: _______ Dates: ___________________________ # Bad Checks Last 12 Mo. _______ Skipped: _________
Eviction filed: ______ Reason: ________________________ Evicted: ______ Reason: ____________________________________
Outstanding Balance Owed: ____ Amount & Reason Why: ___________________________________________________________
Notice Given: _____ Length Required: _________Security Deposit: $_________ Refunded: ____ If Not, Why: _________________
# Occupants: ____ Pets: _____ Additional Info: ____________________________________________________________________
Verified by: _______________________________________Title: ___________________________ Date: ____________________
(Please print)
BANK VERIFICATION (COMPLETED BY THIRD PARTY BANK ONLY)
Date Opened: ___________________________ Average Balance: $ _________________________
Is Account in Good Standing: ___________________
Verified by: ________________________________________Title: ___________________________Date: ___________________
(Please print)
Verification Request V10-2003
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