STATE OF CALIFORNIA - DEPARTMENT OF TRANSPORTATION |
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RESIDENTIAL RENTAL APPLICATION |
Page 1 of 4 |
RW 11-5 (Rev. 6/99) |
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PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Section 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right, upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.
THE LAW PROHIBITS DISCRIMINATION IN HOUSING — DISCRIMINATION BASED ON RACE, COLOR, RELIGION, SEX, MARITAL STATUS, NATIONAL ORIGIN OR ANCESTRY IN THE SALE, RENTAL, OR LEASING OF HOUSING, ACCOMMODATIONS IS PROHIBITED BY THE CALIFORNIA FAIR HOUSING ACT, HEALTH AND SAFETY CODE, SECTION 35700 AND TITLE VI OF THE 1964 CIVIL RIGHTS ACT (42 U.S.C. 2000d, et seq.). If you believe that you have experienced discrimination in the rental of State housing, please contact the nearest local office of the California Fair Employment Practices Commission.
COMPLETE ALL ITEMS - PLEASE PRINT |
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Proposed Occupants |
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Birthdate |
Proposed Occupants |
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Birthdate |
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(3) |
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(2) |
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(4) |
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PROPOSED OCCUPANT (1) |
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Name: |
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Social Security: |
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Home Phone: |
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Driver’s License No.: |
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Address-Number and Street, City, Zip |
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Owner or Manager |
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Phone |
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From |
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To |
Present: |
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Previous: |
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Next Previous: |
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PRESENT EMPLOYMENT |
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PRIOR EMPLOYMENT |
Employer: |
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Business Address: |
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Business Phone: |
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Name/Title of Supervisor: |
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How Long? |
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Current Salary: Weekly $ |
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Monthly $ |
Or Annual $ |
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Name of
Bank:
Name of
Bank:
Address: |
Chk. Acct. No.: _________________ |
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Savgs Acct. No. _________________ |
Address: |
Chk. Acct. No.: _________________ |
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Savgs Acct. No. _________________ |
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FINANCIAL OBLIGATIONS
Payments to: |
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Address: |
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Amount: |
Payments to: |
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Address: |
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Amount: |
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Payments to: |
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Address: |
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Amount: |
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Vehicle: |
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License No. |
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State |
Vehicle: |
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Year: |
License No. |
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State |
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Vehicle: |
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Will you have any waterbeds? ____________________________________________________________________
Why are you vacating your present place of residence? ________________________________________________
RESIDENTIAL RENTAL APPLICATION (Cont'd) |
Page 2 of 4 |
RW 11-5 (Rev. 6/99) |
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PROPOSED OCCUPANT (1) — Continued |
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In Case of Emergency, |
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Address: |
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Notify: |
Number |
/ Street / City /, State /, ZIP Code |
Phone |
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Relationship |
(1) |
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Personal |
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Address: |
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Length of |
Reference: |
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/ Street / City /, State /, ZIP Code |
Phone |
Occupation |
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Acquaintance |
(1) |
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(2) |
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PROPOSED OCCUPANT (2)
Name: |
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Social Security: |
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Home Phone: |
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Driver’s License No.: |
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Address-Number and Street, City, Zip |
Owner or Manager |
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Phone |
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From |
To |
Present: |
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Previous: |
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Next Previous: |
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PRESENT EMPLOYMENT |
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PRIOR EMPLOYMENT |
Employer: |
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Business Address: |
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Business Phone: |
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Name/Title of Supervisor: |
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How Long? |
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Current Salary: |
Weekly $ |
Monthly $ |
Or Annual $ |
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Name of
Bank:
Name of
Bank:
Address: |
Chk. Acct. No.: ________________ |
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Savgs Acct. No. _________________ |
Address: |
Chk. Acct. No.: ________________ |
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Savgs Acct. No. _________________ |
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FINANCIAL OBLIGATIONS
Payments to: |
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Address: |
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Amount: |
Payments to: |
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Address: |
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Amount: |
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Payments to: |
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Address: |
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Amount: |
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Vehicle: |
Make: |
Model |
Year: |
License No. |
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State |
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Vehicle: |
Make: |
Model |
Year: |
License No. |
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State |
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Vehicle: |
Make: |
Model |
Year: |
License No. |
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State |
Will you have any waterbeds? ____________________________________________________________________
Why are you vacating your present place of residence? ________________________________________________
RESIDENTIAL RENTAL APPLICATION (Cont’d) |
Page 3 of 4 |
RW 11-5 (Rev. 6/99) |
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PROPOSED OCCUPANT (2) — Continued |
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In Case of Emergency, |
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Address: |
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Notify: |
Number |
/ Street / City /, State /, ZIP Code |
Phone |
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Relationship |
(1) |
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Personal |
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Address: |
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Length of |
Reference: |
Number |
/ Street / City /, State /, ZIP Code |
Phone |
Occupation |
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Acquaintance |
(1) |
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(2) |
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Applicant represents that statements above are true and correct and hereby authorizes verification of references including, but not limited to, the obtaining of a credit report and agrees to furnish additional credit references upon request. Applicant acknowledges receipt of notification of the relevant provisions of the Federal Privacy Act of 1974.
The undersigned makes application to rent State of California, Department of Transportation property and, upon approval of this application, agrees to sign a rental or lease agreement and to pay all sums due before occupancy.
RENTAL RATES YOU ARE INTERESTED IN $______________________ to $ _________________________
NUMBER OF BEDROOMS REQUIRED: ________________
AREA IN WHICH YOU WISH TO BE LOCATED: COUNTY __________________ CITY ___________________
ADDRESS(ES) OF STATE-OWNED PROPERTY(IES) YOU ARE INTERESTED IN:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
TYPE OF PROPERTY: |
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Single Family Residence |
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Apartment |
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Agricultural |
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Other: _________________________________ |
_____________________________ |
________________ |
_____________________________ _________________ |
Signature |
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Date |
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Signature |
Date |
INFORMATION COLLECTION AND ACCESS
The Information Practices Act of 1977 (Civil Code Section 1798 et seq.) requires the following information to be provided when collecting information from individuals.
AGENCY NAME:
Name, Title, Address, and Telephone Number of Official Responsible for Information Maintenance
Authority for the maintenance of information: Streets and Highways Code Section 104.6
Caltrans Right of Way Manual, Section ________________
State Administrative Manual, Sections 8072.3, 8790.7 and 10510 and Government Code Section 12419.5
The disclosure of all items of information requested is mandatory in that this Rental Application will not be processed if any portion of the requested information is not provided.
The information provided in this form will be used by the Department of Transportation to determine the suitability of the applicant to rent.
All applicants have the right of review files containing personal information that are kept on them by the Department of Transportation. Upon request and proper identification, applicants may inspect all personal information contained in any record maintained on them during the regular business hours of the Department.
Page 4 of 4
RESIDENTIAL RENTAL APPLICATION (Cont’d)
RW 11-5 (Rev. 6/99)
NOTICE TO APPLICANTS DESIRING TO RENT DEPARTMENT OF TRANSPORTATION PROPERTIES
ONLY STATE EMPLOYEES ARE AUTHORIZED TO REPRESENT THE DEPARTMENT OF TRANSPORTATION. COMMISSIONS OR FEES ARE NOT CHARGED. REAL ESTATE BROKERS, SALESMEN, OR NON-STATE EMPLOYEES ARE NOT AUTHORIZED TO REPRESENT THE DEPARTMENT OF TRANSPORTATION IN THE RENTAL OF STATE-OWNED PROPERTIES.
Your attention is directed to the following conditions with which each tenant will be expected to comply:
1.All rents pertaining to State-owned properties are due and payable on the first day of the month and, in any event, must be received by the Department of Transportation Accounting Office no later than the tenth day of each month. Failure to comply with this requirement will make it mandatory that the tenant be requested to vacate.
2.Any property rented after the first day of the month will necessitate an advance rental payment prorated on a 30-day month. A deposit equivalent to one month’s rent may be required.
NOTE: A deposit is a sum of money that is to be held by the Department of Transportation during the occupancy of the tenant and should not at any time be construed as advance rent. Said deposit is recoverable when tenant vacates the property provided that:
a)Tenant notifies the State of their intention to vacate the property. Said notice shall be in writing and contain tenant’s forwarding address.
b)The property is left in a good and livable condition, wear and tear due to normal use and occupancy excepted.
c)There is no unpaid rent due the State for the use of the property.
The State will refund any monies owed to tenant according to California Civil Code Section 1950.05.
3.The initial payment at the time of renting the property shall include the deposit, if required, and any pro-rated rents due for the balance of the rental period.
4.If the property being rented is a single family residence, the tenant will be required to maintain the yard area, particularly the lawn, in a manner consistent with neighborhood standards or tenant will be asked to vacate said property.
Section 7(a)(1) and (b) of the Federal Privacy Act of 1974 (Pub.L. 93.5.79) provides:
“It shall be unlawful for any Federal, State or Local Government Agency to deny to any individual any right, benefit, or privilege provided by law because of such individual’s refusal to disclose his/her social security account number.
“Any Federal, State or Local Government Agency which requests an individual to disclose his/her social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.”
The Department of Transportation’s authority for requesting disclosure is Streets and Highways Code Section 104.6, which reads:
“The Department is authorized to lease any lands which are held for State Highway purposes and are not presently needed therefore on such terms and conditions as the Director may fix and to maintain and care for such property in order to secure rent therefrom.”
The Social Security Number will be used to (1) trace delinquent tenants who have vacated without leaving a forwarding address, and (2) enable the State Controller to collect delinquent rent by the offset procedure required by State Administrative Manual Sections 8072.3, 8790.7 and 10510, as authorized by Government Code Section 12419.5.
The following guidelines for selecting a tenant will include but not be limited to the following:
•The intent and ability of applicant to pay rent.
•The willingness of applicant to maintain the property and improvements.
•The applicant's gross income should equal or exceed four times the rental rate.
•The obtaining of a successful credit report on applicant(s).
•The ability to verify the information contained in this rental application.
