Reconcilable Differences, Inc. 109 Long Point Road  Cape Canaveral, FL 32920

Phone: 321-799-0660  Fax: 321-799-0630

RecDif@earthlink.net    www.ReconcilableDifferences.net

RELEASE OF INFORMATION AUTHORIZATION

Unmarried co-applicants MUST fill out a separate release

Name: ________________________________ SS#_______________________ DOB: ____/____/____

            Last,  First,  MI,   Jr/Sr,  (Prior or Maiden)      

Driver’s License # & State: ___________________________

Spouse: _______________________________ SS#_______________________ DOB: ____/____/____

               Last, First, MI,   Jr/Sr,  (Prior or Maiden)

Driver’s License # & State:____________________________

Present Address: ________________________________________________________________________

                                Street # and Name                                         Apt#          City                                     State                      Zip

Please provide a previous address if you have lived at your current address for less than 24 months

Previous Address: _______________________________________________________________________

                                  Street # and Name                                      Apt#          City                                      State                      Zip

Employment History (minimum two year history – please use back of sheet, if necessary)

Company Name:  ___________________  Phone: ____________  Start Date: _______   End Date: ____

Job Title: _______________________________   Supervisor Name: ____________________

Have you ever been evicted?

Applicant:  YES ______ NO______                            Spouse:  YES _____ NO_____

Have you ever been in litigation with a landlord?

Applicant:  YES ______ NO______                            Spouse:  YES _____ NO_____

Have you applied for residency anywhere in the past 2 years, but did not move in?

Applicant:  YES ______ NO______                            Spouse:  YES _____ NO_____

Have you ever had adjudication withheld or been convicted of a crime?

Applicant:  YES ______ NO______                            Spouse:  YES _____ NO_____

Bank Name/City: __________________________________

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN, IN DETAIL, THE CIRCUMSTANCES REGARDING THE SITUATION ON THE BACK OF THIS SHEET.

Applicant(s) represents that all of the above statements and information on the application for rental are true and complete, and hereby authorizes an investigative consumer report and verification of any and all information relating to residential history (rental or mortgage), employment history, criminal history records, court records and credit records. Applicant acknowledges that false or omitted information herein may constitute grounds for rejection of this application, termination of occupancy, and/or forfeiture of fees or deposits, and may constitute a criminal offense under the laws of this state. I/We hereby release RDI from any liability and responsibility arising from their doing so. Facsimiles of this authorization may be used to facilitate multiple inquiries. In the event you receive a facsimile of this authorization, it should be treated as an original and the requested information should be released to facilitate my/our application for residency.

______________________________________________                _____________________

Signature(s) of Applicant(s)                                                                                       Date