Release of Information Authorization – RUPPERT/YORKVILLE TENANT LEASE APPLICATION Release of Information Authorization - RUPPERT/YORKVILLE LEASE APPLICATION Release of Information Authorization - RUPPERT/YORKVILLE LEASE APPLICATION Release of information authorization I hereby authorize any individual, company or institution to Release to tenant data verification and/or its representative any And all information that they have concerning my character, Reputation, mode of living, employment history, educational History, criminal activity and credit report I hereby release the individual, company or institution and all Individuals connected therewith from all liability for any damage Whatsoever incurred in furnishing such information. Tenant Full Name Date of Birth Signature Clear SS# Date Co-Tenant Full Name Date of Birth Signature Clear SS# Date Payment Name of credit card holder Credit Card Number Indicate Type Of Card Expiration Date Signature of card holder Clear TENANT DATA VERIFICATION CO. INC.SERVICING THE REALTY INDUSTRY344 PORTION ROADLAKE RONKONKOMA, NEW YORK 11779TEL.# (631) 615-2415 FAX# (631) 615-2422 I HEREBY AUTHORIZE TENANT DATA VERIFICATION, CO., INC., TO CHARGE MY CREDIT CARD FOR THE PURPOSE OF OBTAINING A CREDIT BACKGROUND. I (WE) RELEASE T.D.V. FROM ANY AND ALL LIABILITY FROM DOING SO. Name of Credit Card Holder Billling of Credit Card Holder City State Zip Code Credit Card Number Expiration Date Indicate type of card VisaMasteCardAmerican ExpressDiscovery Security Code Signature of Card Holder Clear Please provide documentation for each item listed Name Address Assets Total of cash in banks, CMA's, CD's, etc. (see Schedule A) Securities (see Schedule B) Real Estate (see Schedule C) Pension Funds (see Schedule D) Life Insurance Cash Surrendered Value (see Schedule E) Other Assets (see Schedule F) Liabilities Mortgage Payable (see Schedule C) Other Liabilities (see Schedule G) Total Liabilities Net Worth Income Salary Dividends & Interest Other (see Schedule H) Total Income Signature Applicant Clear Date Signature Co-Applicant Clear Date A. Bank Information Name, Address Type of Account Cash Balance Name, Address Type of Account Cash Balance Name, Address Type of Account Cash Balance B. Securities Description of Security No. of Shares Market Value Description of Security No. of Shares Market Value Description of Security No. of Shares Market Value C. Real Estate Location of Property Market Value Current Amt of Mortgage Location of Property Market Value Current Amt of Mortgage Location of Property Market Value Current Amt of Mortgage D. Pension Funds E. Life Insurance Beneficiary, Insurance Co. Cash Surrender Value Cash Surrender Value Beneficiary, Insurance Co. Beneficiary, Insurance Co. Cash Surrender Value F. Other Assets Description Amount Description Amount Description Amount G. Other Liabilities (other than Mortgages) Description Amount Description Amount Description Amount H. Other Income Source Of Income Amount per Annum Source Of Income Amount per Annum Source Of Income Amount per Annum Email If you are human, leave this field blank. Submit Release Of Application Form
