Previous Reference Landlord Statement - PDF

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					        RENTAL/CREDIT APPLICATION & CREDIT REPORT RELEASE FORM
          AUTHORIZATION FOR LANDLORD REFERENCE VERIFICATION

The following information is provided to the Landlord for the purpose of verifying
Credit History and Rental History of the named applicant. Duplicate as necessary
for additional applicants.

FULL
NAME_____________________________________________________________

DATE OF
BIRTH____________________________________STATE_________________

SOCIAL SECURITY #________________________________

HOME
ADDRESS_________________________________CITY______________STATE
ZIP___________

HOME PHONE:_____________________FAX: __________________________

BUSINESS PHONE: _________________FAX: __________________________

PREVIOUS HOME ADDRESSES WITH ZIP CODES (IF LESS THAN 3 YEARS AT
PRESENT ADDRESS)
PREVIOUS LANDLORD REFERENCES (Cont. Next Page):




DRIVER’S LICENSE # OF
APPLICANT_________________________STATE______

___________________________________                                                 _______________________
Signature                                                                           Date
Application Authorization: Please Read Carefully:
This statement is to clarify that all information provided in this Credit Application is, to the best of applicant/s knowledge, accurate and
truthful. I (we) the applicant/s hereby authorize PROVISION BROKERAGE SERVICES, INC and the potential Landlord to investigate
and verify all information through a Credit Report, LANDLORD REFERENCE CHECK and other methods of background inquiry. This
form shall authorize former and current Landlords to release payment history and length of term information as needed. This lease
application is neither an offer to lease nor a binding agreement to lease space within Landlord’s property. The preparation and submittal
of this form does not constitute a reservation on Landlord’s property or an obligation on the part of the Tenant to lease space within
Landlord’s property. Landlord and Tenant acknowledge that only a fully executed lease agreement is binding upon the parties. This
application is provided in order that Landlord might determine the nature of Tenant’s business activity, credit worthiness, and business
operating experience. Landlord agrees to keep this and other documents of similar nature in strict confidence, for the use of Landlord.
The information may be disclosed, however, to any other party (i.e. prospective purchaser, mortgagee, etc.) on a “need to know” basis.
Tenant authorizes Landlord to obtain a credit report and exchange credit information for Landlord’s consideration of Tenant’s credit
worthiness regarding this application. All applicants herein agree and acknowledge that no other real estate firms/agents are involved in
this transaction and that Provision Brokerage Services, Inc. represents the property owner in any negotiations related hereto, which
applicant is hereby seeking to be a candidate for according to the terms and conditions herein. Thank You.




                                                                                                                                           1
PREVIOUS LANDLORD REFERENCES (Cont. from previous page):
Please include Landlord Name, Location Address, and Contact Number for each
Landlord:




                                                                              2
Duplicate for each co-applicant as needed.

CO-APPLICANT (if any)             ____________________________________________

DATE OF
BIRTH____________________________________STATE_________________

SOCIAL SECURITY #________________________________

HOME
ADDRESS_________________________________CITY__________STATE ____
ZIP___________

HOME PHONE:__________________________FAX: ______________________

BUSINESS PHONE: __________________________FAX: ___________________

PREVIOUS ADDRESSES WITH ZIP CODES (IF LESS THAN 3 YEARS AT
PRESENT ADDRESS)




DRIVER’S LICENSE # OF
APPLICANT_________________________STATE______

___________________________________                           ______________________
Signature                     Date

Application Authorization:
This statement is to clarify that all information provided in this Credit Application is, to the best of
applicant/s knowledge, accurate and truthful. I (we) the applicant/s hereby authorize PROVISION
BROKERAGE SERVICES, INC and the potential Landlord to investigate and verify all information
through a Credit Report and other methods of background inquiry. This lease application is neither
an offer to lease nor a binding agreement to lease space within Landlord’s property. The
preparation and submittal of this form does not constitute a reservation on Landlord’s property or
an obligation on the part of the Tenant to lease space within Landlord’s property. Landlord and
Tenant acknowledge that only a fully executed lease agreement is binding upon the parties. This
application is provided in order that Landlord might determine the nature of Tenant’s business
activity, credit worthiness, and business operating experience. Landlord agrees to keep this and
other documents of similar nature in strict confidence, for the use of Landlord. The information may
be disclosed, however, to any other party (i.e. prospective purchaser, mortgagee, etc.) on a “need
to know” basis. Tenant authorizes Landlord to obtain a credit report and exchange credit
information for Landlord’s consideration of Tenant’s credit worthiness regarding this application.
The above application authorization applies to each applicant signing on this application. All
applicants herein agree and acknowledge that no other real estate firms/agents are involved in this
transaction and that Provision Brokerage Services, Inc. represents the property owner in any
negotiations related hereto, which applicant is hereby seeking to be a candidate for according to
the terms and conditions herein. Thank You.



                                                                                                       3
PREVIOUS LANDLORD REFERENCES (Cont. from previous page):
Please include Landlord Name, Location Address, and Contact Number for each
Landlord:




                                                                              4
                  CONFIDENTIAL FINANCIAL STATEMENT
               Duplicate as needed for each applicant/guarantor

Name       _____________________________


Social Security #   _______________________________

Address      _________________________________________

Business Ph         ____________________________

Residence Ph        ________________________________

Occupation      ____________________________________

Employer            ________________________________

Employer’s Address
________________________________________________

________________________________________________

Additional Guarantor Name    _________________________________

Social Security # ________________________________

Address      _________________________________________

Business Ph         ________________________________

_________________________________________________

Residence Ph        ________________________________

Occupation _________________________________

Employer            ________________________________

Employer’s Address

__________________________________________________________________




                                                                  5
          CERTIFIED PUBLIC ACCOUNTANT (CPA) REFERENCE LETTER


TO BE COMPLETED BY APPLICANT:

Reference Relating to:
__________________________________________________________
(Please print name of Individual Guarantor applying to engage in a Lease Agreement in
the name of a business organization.)

Name of Business Organization:

____________________________________________________________________

Address:
____________________________________________________________________

Social Security #_____________________         or

Federal Tax ID #______________________

TO BE COMPLETED BY CPA AND RETURNED WITH APPLICATION:

The above-named individual and/or business organization is applying to be considered
for a commercial real estate lease agreement in the state of Georgia.

I hereby certify that I have performed an ______ audit or _____ review of the business
organization’s and/or individual guarantors financial information and that said business
organization and/or individual guarantor has a minimum net worth

in the amount of $__________________________________________________

[ATTACH A CERTIFIED COPY OF CPA AUDITED OR REVIEWED FINANCIAL STATEMENTS
TO APPLICATION]

Printed Name:
_______________________________________________________________

Signature of Certified Public Accountant (CPA): _________________________

Certification Number : _________________            Date: __________________

Sworn to before me this _____________day of _______________, year _______.

______________________________________
 Notary Public

My Commission Expires:___________________
(Seal)


                                                                                        6
                              ASSETS
      ALL LIQUID ASSETS MUST BE ACCOMPANIED BY VERIFICATION;
      DUPLICATE AS NECESSARY FOR EACH APPLICANT/GUARANTOR
       ATTACH ADDITIONAL SUPPORTING DOCUMENTS AS NEEDED

Cash (other than amounts shown in banks)                  $_________________

Automobiles                                               $_________________

Cash in Banks (Schedule 1)                                $_________________

Other investments (Schedule 3)                            $_________________

Accounts Receivable (Schedule 2)                          $ _________________

Personal Property                                          $ _________________

Notes Receivable (Schedule 2)                             $__________________


Net Worth of any Business Owned

Stocks and Bonds (Schedule 3)                              $_________________

(Please include CPA audited or reviewed financial statement)

Real Estate (Schedule 4)                                   $__________________

Other Assets                                               $__________________



                                                 Total         $______________

                                   LIABILITIES

Notes Payable to Others (Schedule 7)                     $_________________

Loans Against Life Insurance (Schedule 6)                $_________________

Installment Loans Payable (Schedule 7)                   $_________________

Other Liabilities                                        $_________________

Accounts Payable                                         $_________________


                                                                                 7
Liens on Real Estate (Schedule 5)               $ _________________

Taxes Payable                                   $_________________

Long Term Debts                                 $_________________


                                         Total $_________________

                                    Net Worth    $_________________



Salary                                          $_________________

Taxes & Assessments                              $_________________

Dividends                                       $_________________

Child Support/ Alimony                          $ _________________

Interest                                        $_________________

Mortgage Payments                               $_________________

Commissions                                     $________________

Contract Payments                               $_________________

Rentals                                         $_______________

Insurance                                       $_______________

Other                                           $_______________

Other                                           $_______________

                                         Total $_______________




                                                                      8
                               SCHEDULE OF ASSETS

Schedule 1 Cash in Banks & Savings and Loan & Checking Accounts **
                             90 Day Avg
       Bank Name              Balance        Account #    Balance




                                                   Total $_______________
**For each account, submit a verified statement from each banking institution, to
include Name of Account, Current Balance, Account Number, Length and Specific
Dates of Account. The accounts must have been open and on deposit for a
minimum of ninety (90) days prior to the date of application.

Schedule 2 Receivables
                                                         Maturity   Unpaid
 Name of Debtor         Collateral       Payments         Date      Balance




                                                 Total $_______________
Schedule 3 Stocks and Bonds
   # of                                  Amount Carried          Present
  Shares         Description              on My Books          Market Value




                                                Total   $_______________
Schedule 4 Real Estate (If additional space is necessary, attach separate
sheet)
   Address/Legal        Type of      Monthly Original        Estimated
    Description        Property       Income      Cost     Present Value




                                                 Total        $_______________



                                                                                    9
Schedule 5 Mortgages of liens on Real Estate
         Name of Creditor               Payments               Unpaid Balance




                                             Total        $_______________
Schedule 6 Cost of Maintaining Office
 Rent                      __________________
 Utilities                  __________________
 Telephone                __________________
 Clerical Help             __________________
 Other (Describe)         __________________
 Other (Describe)

                                             Total      $_______________
Schedule 7 Notes Payable to Others
   Name of                                                            Unpaid
   Creditor        Address         Payments Collateral               Balances




                                                Total        $_______________
I, by signing and filing this application, authorize any person or institution to which
reference is made by me in connection with this application, to release or divulge to
the potential Landlord or its representative any information in the possession of
such person or institution regarding me. I hereby approve any investigation on my
credit background.

Primary Applicant/Guarantor

Printed Name ________________________________________

Signature _______________________________________

Date _______________________________

Sworn to before me this _____________day of _______________, year _______.

______________________________________
 Notary Public

My Commission Expires:___________________
(Seal)


                                                                                     10
Lease Application Cont:

I, by signing and filing this application, authorize any person or institution to which
reference is made by me in connection with this application, to release or divulge to
the Landlord or its representative any information in the possession of such person
or institution regarding me. I hereby approve any investigation on my credit
background.

Applicant/Guarantor #2

Printed Name: __________________________________

Signature _______________________________________

Date _______________________________


Sworn to before me this _____________day of _______________, year _______.

______________________________________
 Notary Public

My Commission Expires:___________________
(Seal)

I, by signing and filing this application, authorize any person or institution to which
reference is made by me in connection with this application, to release or divulge to
the Landlord or its representative any information in the possession of such person
or institution regarding me. I hereby approve any investigation on my credit
background.

Applicant/Guarantor #3

Printed Name: __________________________________

Signature _______________________________________


Date _______________________________


Sworn to before me this _____________day of _______________, year _______.

______________________________________
 Notary Public

My Commission Expires:___________________ (Seal)


                                                                                     11
                   PROSPECTIVE TENANT QUESTIONNAIRE

Please complete in full. If you need more space to respond to any of the
questions, please continue of a separate sheet of paper.

Individual(s) ____________________         Corporation ____________________

LLC ____________________

What kind of business do you propose to operate at the center?




What is your experience at operating such an enterprise? (Please provide specifics)
(Attach any awards, reviews, Landlord reference letters, etc. that you feel support
your operating experience.)




What improvements do you plan to make to the Premises (fixtures, carpet, etc.)
(Please provide a scale drawing with proposed improvements along with this letter
of intent.)




Do you have any other comments or information that you feel the Landlord should
take into account in evaluating your proposed store or restaurant?




                               THANK YOU !




                                                                                    12

				
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