Case Manager Los Angeles
Resume:
Background Check Request
Protect Sensitive Personal Information:
Obtaining a background check requires the retrieval and sharing of sensitive personal information. Background check documents contain confidential information, some or all of which may be protected health information as defined by the federal Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule. When submitting the forms to request a background check, please do not put any identifying information, such as full names, in the email body or subject line. Review HIPAA guidelines. Information that may be on the background check:
Social Security Verification: validates the applicant's Social Security number, date of birth and former addresses.
File Identification and Fraud Search
Credit Summary and Account Details
This is a hard inquiry into your credit history, which may impact your score
24 month history chart - credit score and risk model from bureaus
Collection accounts reported by the bureau
Eviction History
Check Scan
Prior Employment Verification
Public Records Reported By The Bureau
Prior Inquiries
Ensure accuracy:
Once you have received a copy of the background check, please review it carefully with your participant to ensure that the information reported is correct, and is relevant to them. If any section of the report reflects information that is not related to your participant (some results may be due to a similar name or SSN), please call LeaseUp at 323-***-**** and we will remove the irrelevant information and provide an updated report. Obtaining a background check:
1. Review ROI carefully with participant.
2. Case manager and Participant must sign the ROI and acknowledge information that will be shared.
3. Forms must be completely filled out and signed. I acknowledge that I have read and fully understand the above information: Case Manager Name (Print) Case Manager Signature
Date
Information Disclosure Consent
Housing Partnerships Program 1 of 1
I (Participant Name) DOB: hereby authorize People Assisting the Homeless (PATH) to release information pertaining to the Housing Location Tenant Screening Services. Tenant Screening information collected by PATH, i ncluding credit/economic, criminal, sex offender, employment, tenancy history and other information related to my background check may be disclosed to the following entities as part of Housing Location Risk Mitigation Program, and for auditing purposes : Property Owners/Landlords
Los Angeles Homeless Services Authority
Veterans Administration
Los Angeles County Department of Mental Health
Los Angeles County Department of Health Services
Public Housing Authorities
Referring Agency Provider Name and Contact:
Other: The disclosure of information/records authorized herein is required for participant linkage to assistance and services. Release of information to selected entities is valid for one year from date of signature. This authorization provides for information disclosure between the individual listed above and the entities indicated above. By providing consent, I hereby release PATH (People Assisting The Homeless), and its officers, employees, affiliates and partners from any claims, damages or liabilities of any kind, that may directly or indirectly result from the use, disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to me.
Participant Signature
Participant Name
Date
Staff Member Signature
Staff Member Name
Date
Referring Staff Member Agency
Participant I _D _ # _
Staff Member Phone
Staff Member Email
Completed forms and any questions may be sent to *********@*****.*** Revised 9/2019
Form Provided by Contemporary Information Corp. For Membership Information Call 800-***-****
or Visit our Website at www.FLFUHSRUWV.com
Form 157.1 © 2009 (Revised )
APPLICATION TO RENT
(All sections must be completed) Individual applications required from each occupant 18 years of age or older. Last name First Name Middle Name Social Security Number or ITIN Other names used in the last 10 years Work phone number Home phone number Date of birth E-mail Address Mobile/Cell phone number Photo ID/Type Number Issuing government Exp. Date Other ID Present Address City State Zip
Date in Date out Owner/Agent Name Owner/Agent Phone Number 1.
Reason for Moving Current Rent
$ /Month
Previous Address City State Zip
Date in Date out Owner/Agent Name Owner/Agent Phone Number 2.
Reason for Moving
Previous Address City State Zip
Date in Date out Owner/Agent Name Owner/Agent Phone Number 3.
Reason for Moving
Name Name
Name Name
Proposed
Occupants:
List all in
addition to
yourself
Name Name
Will you have
pets?
Describe Will you have a waterbed Describe
How did you hear about this rental?
I am am not a member of the Armed Forces (including the National Guard and Reserves) Present occupation or source of income Employer Name Dates of Employment Supervisor’s phone number Employer Address
A.
Name of your supervisor City, State, Zip
Present occupation or source of income Employer Name Dates of Employment Supervisor’s phone number Employer Address
B.
Name of your supervisor City, State, Zip
Current Gross Income
$
3HU Check one
Week Month Year Please list ALL of your financial obligations below Name of your bank Branch or address Account Number Revised 9/2019
Form Provided by Contemporary Information Corp.
For Membership Information Call 800-***-****
or Visit our Website at www.cLFUHSRUWV.com
Form 157.1 © 2009 (Revised )
Automobile: Make: Model: Year: License #: Automobile: Make: Model: Year: License #: Other motor vehicles: Have you ever filed for bankruptcy? Yes No Have you ever been evicted or asked to move? Yes No Applicant represents that all the above statements are true and correct and hereby authorizeV verification of the above items including, but not limited to, the obtaining of a credit report and agrees to furnish additional credit references upon request. Applicant consents to allow Owner/Agent to disclose tenancy information to previous or subsequent Owner/Agents. Owner/Agent will require payment of $, which is to be used to screen Applicant with respect to credit history and other background information. The amount charged is itemized as follows: 1. Actual cost of credit report, unlawful detainer (eviction) search, and/or other screening reports $ 2. Cost to obtain, process and verify screening information (may include staff time and other soft costs) $ 3. Total fee charged $
The undersigned is applying to rent the premises designated as: Apt # Located at The rent for which is $ per . Upon approval of this application, and execution of a rental/lease agreement, the applicant shall pay all sums due, including required security deposit of $, before occupancy. Date Applicant (signature required)
OUR CODE FOR EQUAL HOUSING OPPORTUNITY
We support the spirit and intent of all local, state, and federal fair housing laws for all residents without regard to race, color, sex, religioQ, mental or physical disability, age, marital status, sexual orientation, family status, or national origin. We reaffirm the belief that equal opportunity can best be accomplished through effective leadership, education, and the mutual cooperation of owners, managers, and the public.
Therefore, we agree to abide by the following provisions of this Code for Equal Housing Opportunity:
· We agree that in the rental, lease, sale, purchase, or exchange of real property, owners and their employees have the responsibility to offer housing accommodations to all persons on an equal basis.
· We agree to set and implement fair and reasonable housing rules and guidelines and will provide equal and consistent services throughout our residents’ tenancy.
· We agree that we have no right or responsibility to volunteer information regarding the racial, creed, or ethnic composition of any neighborhood, and we do not engage in any behavior or action that would result in “steering.”
· We agree not to print, display, or circulate any statement or advertisement that indicates any preference, limitations, or discrimination in the rental or sale of housing.
Name of Creditor Address Phone Number Monthly Payment Amt. In case of emergency, notify: Address: Street, City, State, Zip Relationship Phone 1.
2.
Personal References: Address: Street, City, State, Zip Length of Acquaintance
Occupation Phone
1.
2.
Revised 9/2019
Revised 9/2019
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