Landlord:__________________________________________________________________________

Address:_________________________________________________

City:____________________________________________________

State:___________________________________________________

Zip:_____________________________________________________

Phone:_____________

Email:__________________________________________________  

Property Address:__________________________________________

Apt:______________

City:_____________________________________________

State:____________________________________________

Zip:_____________________

All tenants listed on lease:______________________________________________

Rent:$______________ due on the ________________

Late Charge: $____________

Back Rent: $__________________

Back rent description:______________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Was the property built prior to 1978?  Yes    No

Is the Property Registered with MDE?  Yes   No

Is the tenant in the military?  Yes   No

Lead Certificate Number: _______________

FAX TO: 443-291-6212