Housing Trust Fund Rental Assistance Program
Request for Lease Approval	

The program participant identified below has located a dwelling unit at:
                                                                                                                                                           (address, unit number, city, zip) he/she wishes to rent. The owner identified below is interested in renting the unit to the participant. The participant and owner are requesting that                                                                            (administrator) review the information below in order to determine if this property is eligible to participate in the Housing Trust Fund Rental Assistance Program. The requested beginning date of the lease is:      .

1.	Type of Property (check one):

 Single Family Home		 Duplex/Townhouse
 Mobile Home		 Single Room Occupancy
 Three to six-unit building	 Building with more than six units	

2.	 Year Built:      

3.	Number of bedrooms:      

4.	Total monthly rent to be charged: $     
	Security Deposit: $     

5.	Utilities and Appliances: (Mark “O” for those furnished by the owner and “T” for those furnished or paid for by the tenant. Indicate the fuel source, where appropriate.)

	      Electricity (lights)	   			      Heating (gas      ; electric      ; other      )

	      Cooking (gas      ; electric      )     	      Hot water (gas      ; electric      )

	      Water/sewer				      Trash Collection

	      Range	      Refrigerator		      Air conditioner

6.	Lease: Owner's lease. (Note: The program requires that the form Housing Trust Fund Rental Assistance Lease Addendum be made part of an owner's lease.)

7.	Administrator Review.  The participant and owner understand that the administrator will review the above information and the proposed lease form, and will inspect the dwelling unit/property for compliance with the program's Housing Quality Standards.  The administrator will notify the participant and owner whether or not the lease and property are acceptable for participation in the program.  The administrator is not obligated to pay any part of the rent on behalf of the participant until the owner executes a Housing Trust Fund Rental Assistance Contract with the administrator and the unit passes the Housing Quality Standards inspection.

8.	By executing this Request for Lease Approval, the owner certifies that the unit is made available, managed, and operated regardless of race, color, creed, religion, sex, national 	origin, disability, familial status, marital status, and status with regard to public assistance.

Household

By: Head of Participant Household	Date	
		
By: Household Member	Date	
		
	Phone Number	

Owner

By: Owner, or authorized representative	Date	
		
Owner’s or representative’s address	Phone Number	
		
	Owner’s TIN/Social Security Number