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The following resident, _________________________________________________, has requested assistance in getting into his/her residence because he/she is locked out of the premises located at _____________________________________________.

Date of request:______________________________________    

Time of request :_____________________________________

The reason the resident is locked out is because of the following reason ____________________________________________________.

The resident understands that the owner or manager must check identification, and/or review files and verify that individual requesting lock out assistance is indeed a valid resident and current lease holder. Non resident are not permitted entry.

The following was shown/given as proof that the individual was a current resident:


The resident understands and agrees to the following fees in regard to lockout assistance:

Charge for lockout assistance during business hours: $15   from 10am to 5pm.

Charge for lockout assistance outside business hours: $30  from 5pm to  10pm.

There is an additional charge of $______ if the residents key is lost and/or the lock has to be completely replaced. All fees are due and payable at time assistance is provided.

Payment received from______________________________________________

Amount received $___________________________________________ Dollars

If payment is not received, resident agrees that the following amount of $___________ is owed and that this amount will be immediately considered as additional rent due, and paid by the following date, ______________________,  or the resident is subject to eviction for nonpayment.

It should also be noted that this is the ______________ time the resident has needed lockout assistance. If assistance is requested more than _____________ times, the following additional terms may also apply:


Residents Signature ________________________________________________

Landlord/Managers Signature _________________________________________

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