Statement of Credit Denial, Termination or Change

Date:	__________________

Applicant's Name:

Applicant's Address:

Description of Account, Transaction or Requested Credit:

Description of Action Taken:

Principal reason(s) for credit denial, termination or other action taken concerning credit (must be completed in all cases):

__ Credit application incomplete	__ Length of residence

__ Insufficient number of credit

references provided	__ Temporary residence

__ Unacceptable type of credit

references provided	__ Unable to verify residence

__ Unable to verify credit references	__ No credit file

__ Temporary or irregular employment	__ Limited credit experience

__ Unable to verify employment	__ Poor credit performance with us

__ Length of employment	__ Delinquent past or present credit

obligations with others

__ Income insufficient for amount	__ Garnishment, attachment, foreclosure,

of credit requested	repossession, collection action, or

judgment

__ Excessive obligations in relation

to income	__ Bankruptcy

__ Unable to verify income	__ Value or type of collateral not sufficient

__ Other:

To obtain a copy of your credit report, contact Accudata Credit Systems at 1-800-475-7603 or 573-
893-7500.

Signature of landlord or authorized representative