All applicants must complete this financial information and criminal background acknowledgment form. All financial information provided will remain confidential. It is our policy to lease to residents without regard to race, color, national origin, age, ancestry, sex, religious creed, handicap, or disability. This is a tobacco-free community.

Applicant Screening for Drug Abuse or Other Criminal Activity Release

1. I hereby authorize Heritage Run Estates LLC, its agents, successors and assigns (“HRE”) to access, obtain and examine all of my credit and criminal records, including but not limited to criminal conviction background checks, sex offender registration records, drug-related background information, landlord verification and any other applicable documentation, whether in print or electronic form (“screening records”), it deems reasonably necessary, at HRE’s sole discretion, to made a determination concerning my entering into a lease with a HRE senior living community (“HRE community”)

2. I understand that the screening records may be obtained, and the screening review performed, by HRE directly or indirectly through a third party engaged by and acting on behalf of HRE, such as a designated Public Housing Agency or a contractor selected by HRE for the purpose of conducting criminal background and credit checks.

3. I understand and agree that my application for admission to a HRE community will be summarily denied if I refuse to give access to the screening records by executing this Consent and Release Form (“Release”). Falsified information will be grounds for denial of application.

4. I understand that the screening records will be kept confidential and will not be used for a any improper purpose. HRE will not misuse or improperly disseminate the screening records to third parties.

5. I understand that HRE will keep the screening records for a period of three (3) years following the end of my tenancy, at which time HRE will destroy them.

6. I hereby indemnify and hold harmless HRE, its officers, agents, directors and employees, from any and all claims, actions suit, agreements or liabilities relating to HRE’s use of the screening records as described above.

I certify that I have understood the contents of this Release and have had the opportunity to ask questions which have been answered to my satisfaction. I have voluntarily executed this Release on behalf of my heirs, executors, assigns and myself on the date shown below.

I attest that the information provided is complete and correct to the best of my knowledge.

The undersign acknowledge that this is only an application to lease. It is not an agreement by the landlord or the applicant to enter into a lease agreement.

Application