Failure to pay

Owner's First Name *

Owner's Last Name *

Owner's Street Address *

City *

State*
GeorgiaTexas

Primary Contact number *

Secondary Contact number

Owner's Email Address *

Tenant #1 Name: *

Tenant #1: DOB

Tenant #1 Phone number

Tenant #1 Email

Tenant #2 Name:

Tenant #2: DOB

Tenant #2 Phone number

Tenant #2 Email

Tenant #3 Name:

Tenant #3: DOB

Tenant #3 Phone number

Tenant #3 Email

Tenant #4 Name:

Tenant #4: DOB

Tenant #4 Phone number

Tenant #4 Email

Tenent's Street Address *

City *

State*

County: *

Do you have a Rental License for your rental property: *
YesNo

If yes, Enter the Current License Number:

Is this property Government Subsidized?
YesNo

If yes, Enter Tenant Portion:

If yes, Enter Tenant Portion:
Condo/ApartmentTownhouse/RowhomeSingle Family HomeBasement OnlyTop Floor OnlyRoomCommercialTrailerLandOther

Number of levels:

Name of the Complex or Property Name:

Start Date for the Lease: *

End Date for the Lease: *

Lease *
CurrentMonth to monthExpired

This section is for properties built before 1950. The Property is:
is NOT affected under 6-801, Environment Articleis affected under 6-801, Environment Article

The Property is:
MDE RegisteredIS NOT MDE Registered

Inspection Certificate Number:

The Owner is unable to state Certificate Number because:
Not applicableProperty is exemptTenant refused to access or vacate

Monthly Rent Amount: *

Rent is due on *
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Type of period
WeeklyMonthlyQuarterlyYearly

Months late:
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Total Amount of Rent Due: *

Total Amount of Late Fees Accrued: *

Total Amount of Rent Due: *

The Landlord requests future rent between the date of complaint and date of judgment in the amount of $: *

Total Amount of Rent Due: *

List any prior judgments against the tenant: *

Are there any outstanding repairs the tenant can complain about in court? *

Military Service *
The tenent is in military serviceThe tenent is not in military service

Are all the tenants on the lease listed above *
YesNo

Comment: (you can also email us your comment)
Comment: (you can also email us your comment)

Lease Agreement

Rental License

Rental History/Statement

Other

Name: I do solemnly declare and affirm under the penalty of perjury that the matters and facts set forth above are true to the best of my knowledge and belief: *

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