EZPay

Design Your Building

For your

EZPay Application

We are honored to have you as a part of the ULTIMATE family!

Applicant Information

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First name

Last name

Mobile Phone

SSN last 4

Date of Birth MM/DD/YYYY

Driver’s License/ID Number

Driver’s License/ID State

License/ID Exp Date

In Active Bankruptcy?

Yes

If the applicant is in active bankruptcy, the application for Rent-to-Own with EZPay will not be approved.

Employment

Occupation

Employer Name

Employer Zip Code

Employer Phone

Employment length Years/Months

Applicant’s MONTHLY Income (USD)

Other Household Income (USD)

Monthly Property Payment

Property Information

Own

Rent

Street Address

City

State

Zip Code

Name shown on the deed of the delivery property

Building Coverage

This coverage is an additional $20 per month along with your payment. It is not required. However, if you decline you will be required to add the building to your homeowner’s insurance policy.

Include optional Coverage / Insurance?(required)

Yes

(If declined coverage) Insurance Name

Insurance Phone

Policy Number

Notes

Additional Notes