Claim for Damages and Cleaning

This form must be signed by the person who inspected the apartment following departure of the tenant.
Attention apartment complex manager: Complete a separate form for each line item on the bill that was sent to the tenant. Mail this form and supporting documentation to the tenants new address of record. Date and time of inspection: __________________________________________ Describe the damages or chargeable service. For trash removal or cleaning services, state the location, type and amount of debris and state the approximate amount of time that was required to clean or remove the debris. Please print clearly.

Under penalty of perjury, I, __________________________________________, affirm that I personally witnessed the above-described loss, debris, or damage, that I have read the above claim, know the contents thereof and believe the same to be true.

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Signature of apartment inspector (Same as name printed above) _____________________________________________________ Position or title

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Date signed