Failure To PayOwner InformationOwner's First Name *Owner's Last Name *Owner's Street Address *City *ZIP Code *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCPrimary Contact No. *Secondary Phone No. *Owner's Email Address *Confirm Email Address *Property InformationCountry of Rental Property *Select Country of Rental PropertyAnne ArundelBaltimore CityBaltimore CountyCalvert CountyCarroll CountyCecil CountyCharles CountyFrederick CountyHarford CountyHoward CountyMontgomery CountyPrince George's CountySt. Mary's CountyTenant Street Address *Unit No. / Apt No. / FloorCity *ZIP Code *State *Select StateMarylandWashington, DCVirginiaDo you have a Rental License for your rental property? *SelectYesNo, Do not have oneNo, Not requiredType of Rental Property *Select Rental Property TypeCondo/ApartmentTownhouse/RowhomeSingle Family HomeBasement OnlyTop Floor OnlyRoomCommercialTrailerLandOtherName of the Complex or Property NameNumber of bedroomsSelect Number of Bedrooms012345+Number of levelsSelect Number of Levels1 Floor2 Levels3 Levels4+ LevelsWas the property built before 1978SelectYesNoNot sureInspection Certificate NumberThe Owner is unable to state Certificate Number becauseSelectNot ApplicableProperty is exceptTenant refused access or to vacateThe Property isSelectis MDE registeredis not MDE registeredThe Property isThis section is for properties built before 1978. For more information visit www.MarylandEvictionsOnline.com/mde/Selectis not affected under 6-801, Environment Articleis affected under 6-801, Environment ArticleTenant InformationTenant No.1 Name *Tenant 1: Date of BirthTenant 1: Phone No.Tenant 1: Email AddressConfirm Email AddressTenant No. 2 NameTenant 2: Date of BirthTenant 2: Phone No.Tenant 2: Email AddressConfirm Email AddressTenant No. 3 NameTenant 3: Date of BirthTenant 3: Phone No.Tenant 3: Email AddressConfirm Email AddressTenant No.4 NameTenant 4: Date of BirthTenant 4: Phone No.Tenant 4: Email AddressConfirm Email AddressIs this property Government Subsidized?SelectYesNoStart Date of Lease *End Date of Lease *Lease *SelectCurrentExpiredMonth to MonthCase InformationMonthly Rent Amount *USDRent is due on *Select1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21st22nd23rd24th25th26th27th28th29th30th31stType of Period *SelectMonthlyWeeklyQuarterlyAnnualyMonths Late *JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberTotal Amount of Rent Due *USDTotal Amount of Late Fees Accrued *USDCalculationThe Landlord requests future rent between the date of complaint and date of judgment in the amount of $ *USDList any prior judgments against the tenant *Are there any outstanding repairs the tenant can complain about in court? *SelectYes, will explain in CommentsNoNo, None knownMilitary Service *Selectthe Tenant is in the military servicethe Tenant is not in the military serviceAre all the tenants on the lease listed above *SelectYesNoComment: (you can also email us your comment)Lease AgreementChoose FileNo file chosenDelete uploaded fileRental LicenseChoose FileNo file chosenDelete uploaded fileRental History/StatementChoose FileNo file chosenDelete uploaded fileOtherChoose FileNo file chosenDelete uploaded fileName: 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 *Signature (not required on some devices)Start signing your signature hereYour browser does not support e-Signature field.Title *SelectOwnerProperty ManagerAttorneyRelativeOtherToday's Date *How did you hear about usSelectGoogleEmail AdMSN/BingPostcard/MailerCraigslistReferralMet in CourtYelpYellowpagesOtherSubmit
