The Bridges Program participant identified below has found a dwelling unit at the following address that he/she wants to rent: 
Address	Unit Number	City	Zip Code	
     	     	     	     	
Year unit was built 	     			

The owner identified below is interested in renting the unit to the participant. The participant and owner are requesting that the Housing Agency review the information below in order to determine if this property is eligible to participate in the Bridges Program funded by the Minnesota Housing and administered by the Housing Agency. The requested beginning date of the lease is: 
Lease beginning date:      

Type of Property (check all that apply) 	
	Single family home		Duplex/townhouse	 Shared Housing 	
	Mobile home		Single family occupancy		
	Three- to six-unit building 		Building with more than six units	

Bedrooms 	

	Number of bedrooms                                	     	If shared housing, total number of bedrooms in unit 	
Total Monthly Rent to be Charged
     
Security Deposit Required 
     
Utilities and Appliances
Mark “O” for those furnished by the owner; mark “T” for those furnished or paid for by the tenant. Indicate the fuel source, where appropriate. 
O or T	Utilities 	
     	Heating 
(check the applicable fuel source) 		Gas		Electric		Other	
     	Cooking
(check the applicable fuel source) 		Gas		Electric			
     	Hot water 
(check the applicable fuel source) 		Gas		Electric			
     	Other Electric	
     	Water/sewer (circle all that apply)	
     	Trash collection	

O or T	Appliances	
     	Range/stove	
     	Refrigerator	
     	Air conditioner	
     	Utility Allowance Total	
     	If shared housing, pro-rata utility allowance	

Owner and Participant
The owner and the participant MUST COMPLETE the owner’s lease. NOTE: The program requires that the Lease Addendum (Bridges Program Form 12) be made part of the owner’s lease. 
Housing Agency Review 
The participant and the owner understand that the Housing Agency will review the above information and the proposed lease form and will inspect the dwelling unit/property for compliance with the program’s Housing Quality Standards. The Housing Agency will notify the participant and the owner whether or not the lease and property are acceptable for participation in the program. The Housing Agency is not obligated to pay any part of the rent on behalf of the participant until the owner executes a Bridges Contract with the Housing Agency and the unit passed the Housing Quality Standards inspection. 
Request for Lease Approval – Signatures
By executing this Request for Lease Approval, the owner certifies that the unit is made available, managed, and operated regardless of race, color, creed, religion, sex, national origin, disability, familial status, marital status, and status with regard to public assistance. 
Household Signatures 	
Participant Head of Household Signature 	     	
Date	     	
Household Member Signature 	     	
Date	     	
Household Telephone Number 	     	
Owner Signature	
Owner or Authorized Representative	     	
Date 	     	
Address	     	
Household Telephone Number