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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