Vacation / Empty Property Check Request

2. Date Leaving - Date Returning
   Date Leaving - Date Returning Start Date

   —

   Date Leaving - Date Returning End Date

4. Name / Owner

6. Address

8. City

9. State

10. Zip Code

12. Phone

14. Is there a pet left on premises?

    1. Yes
    2. No

15. Where will the pet be left?

    1. Inside
    2. Outside
    3. Both

17. Do you have a security alarm?

    1. Yes
    2. No

19. Name of Alarm Service

20. Phone

22. Will lights be left on a timer?

    1. Yes
    2. No

23. Times and Locations

25. Is there current damage to your home's windows, doors or fence?

    1. Yes
    2. No

27. Where?

29. Any vehicle(s) left in the driveway?

    1. Yes
    2. No

30. Note the license plate number(s)

34. Person(s) Checking Property

36. Name

38. Address

40. City

41. State

42. Zip Code

44. Checking

    1. Daily
    2. Periodically

45. Authorized to enter residence?

    1. Yes
    2. No

47. Vehicle Description(s)

51. Name

53. Address

55. City

56. State

57. Zip Code

59. Checking

    1. Daily
    2. Periodically

60. Authorized to enter residence?

    1. Yes
    2. No

62. Vehicle Description(s)

66. I hereby give consent to the Cottage Grove Police Department to enter my property during the time indicated in my absence for the purpose of inspection to ensure property is secure and further authorize identification / verification to their presence or permission to be there.

    I hereby give consent to the Cottage Grove Police Department to enter my property during the time indicated in my absence for the purpose of inspection to ensure property is secure and further authorize identification / verification to their presence or permission to be there.

68. eSignature

69. Date
    Date

Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

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