Failure to PayOwner's InformationName(Required) Owner's First Name Owner's Last Name Owner's Address(Required) Street Address City State Zip Code Primary Contact Number(Required)Secondary Phone NumberOwner's Email Address(Required) Property InformationCounty of Rental Property(Required)Anne ArundelBaltimore CityBaltimore CountyCalvert CountyCarroll CountyCecil CountyCharles CountyFrederick CountyHarford CountyHoward CountyMontgomery CountyPrince George's CountySt. Mary's CountyTenant's Address(Required) Street Address Unit# / Apt # / Floor City Zip Code State(Required)MarylandWashington, DCVirginiaDo you have a Rental License for your rental property?(Required)YesNo, Do not have oneNo, Not requiredType of Rental Property(Required)Condo/ApartmentTownhouse/RowhomeSingle Family HomeBasement OnlyTop Floor OnlyRoomCommercialTrailerLandOtherName of the Complex or Property NameNumber of bedrooms012345+Number of levels1 Floor2 Levels3 Levels4+ LevelsWas the property built before 1978YesNoNot sureInspection Certificate NumberThe Owner is unable to state Certificate Number becauseNot ApplicableProperty is ExemptTenant refused access or to vacateThe Property isis MDE registeredis not MDE registeredThe Property isis not affected under 6-802, Environment Articleis affected under 6-801, Environment ArticleThis section is for properties built before 1978. For more information visit www.MarylandEvictionsOnline.com/mde/Tenant InformationTenant(Required)NameDOBPhoneEmail Add RemoveIs this property Government Subsidized?YesNoStart Date for the Lease(Required) MM slash DD slash YYYY End Date for the Lease(Required) MM slash DD slash YYYY Lease(Required)CurrentExpiredMonth to MonthCase InformationMonthly Rent Amount:(Required)Rent is due on(Required)1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31stType of Period(Required)MonthlyWeeklyQuarterlyAnnuallyMonths late(Required) January February March April May June July August September October November DecemberTotal Amount of Rent Due(Required) Total Amount of Late Fees Accrued(Required) Total Due The Landlord requests future rent between the date of complaint and date of judgment in the amount of $(Required)Please enter a number from 0 to 9999999.List any prior judgments against the tenant(Required)Are there any outstanding repairs the tenant can complain about in court?(Required)NoYes, will explain in CommentsNo, None knownMilitary Service(Required)the Tenant is not in the military servicethe Tenant is in the military serviceAre all the tenants on the lease listed above(Required)YesNoHave you sent a 10/day Letter of Intent to your tenant ?(Required)YesNoComment: (you can also email us your comment)Lease AgreementMax. file size: 1 GB.Rental LicenseMax. file size: 1 GB.Rental History/StatementMax. file size: 1 GB.OtherMax. file size: 1 GB.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:(Required)Signature (not required on some devices)Title(Required)OwnerProperty ManagerAttorneyRelativeOtherToday's Date(Required) MM slash DD slash YYYY How did you hear about us:GoogleEmail AdMSN/BingPostcard/MailerCraigslistReferralMet in CourtYelpYellowpagesOther
