Claim Form
 RentSecure
 Overview
 Ordering
 Fees/Terms
 Tenant
 Agreement
 FAQ
 Filing Claims
 Contact Us

RentSecure TM Claim Form

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: _________________

 

 

Please contact our webmaster with questions or comments.

Copyright 1998-2009  Jon Wickers Co. Inc.  All rights reserved.

718-352-1000   Fax: 718-352-5271