Damage & Vacancy Loss Claim Form

Damage & Vacancy Loss Claim Form

Part 1 - Owner & Tenant Information

Property Owner/ Manager Name*

Owner/ Manager Mailing Address*

Street Address

Owner/ Manager Street Address 2

Owner/ Manager City State/ Province*

Owner/ Manager Postal/ Zipcode*

Property Owner/ Manager Phone Number*

Phone

Property Owner/ Manager Email Address*

Tenant First Name*

Tenant Last Name*

Unit Address This Claim is for:*

Tenant Street Address

Tenant Unit #*

Tenant Street Address Line 2

Tenant City State/ Province*

Tenant Postal/ Zipcode*

Contract Rent*

What is the reason for moving out?*

(if a vacancy loss claim)

Lease Beginning Date*

Lease End Date*

Part 2: Security Deposit

Enter the amount of the refundable security*

deposit held by owner/ manager:

Pet Security Deposit (If Applicable)

Part 3: Damage Claim

What date was the required move-out inspection

completed?

Damages:

Enter the amount charged to the tenant for tenant-caused damages beyond normal wear & tear (Include receipts or estimates of damages claimed).

Cleaning Costs:

Enter the amount charged to the tenant for cleaning costs above and beyond normal wear and tear. (Include a copy of receipts or estimates of cleaning costs claimed).

Part 4: Vacancy Loss Claim

A Vacancy Loss may be claimed ONLY under the following conditions:

1. The tenant moved without cause during the term of lease without a mutual rescission or 30 day notice.

2. The tenant moved at the end of the lease term without providing 30-day notice.

3. The owner evicted the tenant through court action that could not be prevented by mediation attempts by local

service providers.

**The property owner MUST submit verification that an attempt has been made to re-lease the unit (e.g. leasing reports, online listing, Padmission relisting, etc.)

Which scenario are you filing a vacancy loss claim for?

The tenant moved without cause during the term of the lease without giving 30 day notice.

The tenant moved out at the end of the leasing term without providing 30 day notice.

The owner evicted the tenant through court action that could not be prevented by mediation from local service providers.

Enter the date which the tenant moved out or the date the unit was discovered vacant:

Enter the date of the last payment received on behalf of the tenant:

How long was the unit vacant during the month following the last month payment was received on behalf of the tenant? (If the tenant vacated in April, you would count the days vacant in May).

Vacancy Loss Calculation: Contract Rent divided by 30 days x days vacant:

Part 5: Verification of Claim Parameters

Did you contact Welcome Home, Neighbor upon discovering the unit was vacant and was the inspection completed?*

Yes

Not Applicable

Did you itemize and bill the tenant for damages incurred that exceeded their security deposit? (Include a copy with this form).*

Yes

Not Applicable

Have you included all estimates, quotes, and receipts for claims and checked to see if these figures match those given in this worksheet?*

Yes

Not Applicable

File Upload*

Upload itemized bill(s), photos that clearly display all damages, repair estimates, repair quotes, and receipts

Drag and drop files here or

Part 6: Signature

I hereby certify that the foregoing information is true and correct to the best of my knowledge and belief and that all claims have not been previously paid. I agree and understand that inquiries may be made to verify statements herein.

Signature of Owner:*

Date Signed*

Note to Owner/Manager:

● Allow 10 business days for Welcome Home, Neighbor to process this claim.

● Please attach all required documentation to expedite the processing of this claim.

● Thank you for your assistance and cooperation.

Send me a copy of my responses

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