| Landlord/Owner's First and Last Name: |
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| Landlord/Owner's Mailing Address: |
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| Landlord/Owner's City: |
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| Landlord/Owner's State: |
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| Landlord/Owner's Zip Code: |
(5-digits) |
| Landlord/Owner's Phone: |
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| Landlord/Owner's Email Address:: |
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| Landlord/Owner's Fax Number: |
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| Tenant's First and Last Name: |
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| Tenant's First and Last Name: |
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| Rental Property Address Street 1: |
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| Rental Property Address Street 2: |
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| Tenant's Email Address: |
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| Rental Property City: |
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| Rental Property Zip Code: |
(5 digits) |
| Tenant's Daytime Phone: |
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| Tenant's Evening Phone: |
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Which notice do you want served:
(Choose notice to pay or quit if the tenant will be allowed to stay if arrears are paid in full.) |
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| Is the tenant(s) in the military?: |
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| Date Lease/Rental Agreement was signed: |
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| Is this a lease or month-to-month rental agreement: |
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| Monthly Rent: |
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| The last month full rent was received: |
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| Total amount of rent due, including present month: |
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| Late Fees: |
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| Miscellaneous Fees: |
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