|
This page may be printed and submitted to RentSecure TM as the landlord's claim for damages.
RentSecure TM Account #: ________________________________
Landlord Information
Landlord Name: _________________________________________
Landlord Address: _______________________________________
_______________________________________
_______________________________________
Landlord Phone: _________________________________________
Tenant Information
Tenant Name: ___________________________________________
Tenant Address: _________________________________________
_________________________________________
_________________________________________
Tenant Phone: _________________________________________
Claim Information
Amount Owed: _________________________________________
Basis for Claim: _________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
I, ________________________ as landlord, request that RentSecure TM, acting in the limted capacity of a limited managing agent, debit the tenant's credit card in the sum of ______________________, in compliance with the terms of the security agreement and lease executed by the Tenant. I agree to indemnify and hold harmless RentSecure TM, its officers, employees, agents, consultants, and contractors, from any claims of any nature arising from this act.
x_________________________
Landlord
Dated: _________________
|
