SECURITY/PET DAMAGE DEPOSIT STATEMENT
Amount of Security Deposit $ _________________
Amount of Pet Damage Deposit $ _________________
Accrued Interest $ _________________
TOTAL $ _________________
Unpaid Rent / Late Fees $ _________________
Utilities/Phone/Cable $ _________________
Carpet Cleaning $ _________________
Window Cover Cleaning $ _________________
Other Cleaning $ _________________
Carpet Cleaning $ _________________
Pet Damage $ _________________
Painting $ _________________
Damage Repair/Replacement $ _________________
Key Replacement $ _________________
Other Access Devices $ _________________
Liquidated Damages $ _________________
Other: ____________________ $ _________________
TOTAL $ _________________
Deduct from Security Deposit $ _________________
Deduct from Pet Damage Deposit $ _________________
BALANCE DUE TENANT $ _________________
BALANCE DUE LANDLORD $ _________________
I agree with the amounts noted above and authorize deductions noted above from my Security and/or Pet Damage Deposit. If the total owing to the
Landlord exceeds my deposit(s), I agree to pay the Landlord the excess amount.
Tenant Signature: __________________________________________________________________ Date Signed: ______________________________
Forwarding Address: _________________________________________________________________________________________________________
PART IV - MOVE-IN INSPECTION
I _____________________________________________________ agree that this report fairly represents the condition of the rental unit.
I _____________________________________________________ do not agree that this report fairly represents the condition of the
rental unit for the following reasons:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Tenant's Signature _____________________________________________________________ Date: _______________________________
Landlord's Signature ___________________________________________________________ Date: ________________________________
PART V - MOVE-OUT INSPECTION
I _____________________________________________________ agree that this report fairly represents the condition of the rental unit.
I _____________________________________________________ do not agree that this report fairly represents the condition of the
rental unit for the following reasons:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Tenant's Signature _____________________________________________________________ Date: _______________________________
Landlord's Signature ___________________________________________________________ Date: ________________________________
No. of keys given at move-in _______ Other access devices given at move-in ___________________________________________________________________________________
No. of keys given at move-out _______ Other access devices given at move-in __________________________________________________________________________________
Smoke alarm(s) tested
Move-in: Functioning ____ Not Functioning ____ Comment: _______________________________________________________________________________________________
Move-out: Functioning ____ Not Functioning ____ Comment: ______________________________________________________________________________________________
Furniture
move-in
____ satisfactory or
move-out
Appliances
move-in
____ satisfactory or
move-out
Laundry area
move-in
____ satisfactory or
move-out
Fireplaces, Heating Stoves
move-in
____ satisfactory or
move-out
Other:
move-in
____ satisfactory or
move-out
PART III - continued