RESIDENTIAL TENANCIES ACT
File Number:
T
his claim must be filed with the Director by landlords wishing to retain all or any portion of a security deposit for unpaid rent or
damages or both where the tenant does not consent in writing.
I
t must be filed within 10 days of termination of the lease.
If the unpaid rent or damages or both exceed the amount of the security deposit, the landlord may file an Application to the
D
irector seeking an order for the balance.
RE:
Address of Rental Unit
LANDLORD: TENANT:
Name Name
Address Address
Postal Code Postal Code
DESCRIBE DEDUCTIONS:
$
$
$
$
$
TOTAL (Enter this below at **) $
SECURITY DEPOSIT ACCOUNTING:
Amount of deposit: $ Date paid:
Interest: +
$
Total (deposit + interest): = $
Deductions:**
-
$
Balance refund to tenant = $
(if negative, enter “0”)
I will be filing an Application to the Director for additional payment:
■■
Y
es
■■
No
SIGNATURE: DATE:
SECURITY DEPOSIT CLAIM
THE TENANT HAS READ AND UNDERSTOOD THIS CLAIM AND AGREES WITH THE BALANCE REFUND AS CALCULATED BY THE
LANDLORD:
SIGNA
TURE:
DATE:
If the tenant has consented to this claim, the landlord need not file it with the Director.
Form MIS 94
Rev. 07/03
