Middleton Police Department - Vacation Check Form

Name *

Address *

Physical Street Address

Home Phone Number *

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Vacation Phone Number:

Area Code Phone Number

E-mail *

Leave Date *

Month Day Year

Return Date *

Month Day Year

Alarm System? *

Yes No

Lights Left on? *

Yes No

If lights left on, describe:

Mail Stopped? *

Yes No

Newspaper Stopped? *

Yes No

Lawn Care? *

Yes No

Snow Removal? *

Yes No

Who is taking care of lawn/snow removal?

Keys left with: *

In case of EMERGENCY: *

Special Instructions/Additional Information:

WAIVER:

By completing this form, I affirm that I am the owner of the property indicated and further agree to hold harmless the City of Middleton, the City of Middleton Police Department and any of its agents or representatives, acknowledging that by completing this form and filing same with the City of Middleton Police Department.

I am requesting that a record be maintained that said property will be vacant during the times listed in this form. I further acknowledge and understand that the filing of this form in no way binds nor implies that the City of Middleton Police Department will be responsible for the security and safekeeping of my property.

*

Agree Disagree