Email
example@example.com
What are the full names of the tenant(s) to whom this notice is addressed?
What is the full address of the property referenced in the lease?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For which specific period(s) (e.g., month(s) and year(s)) did the tenant fail to pay rent?
For which month was the rent paid late?
What exact date was it received
-
Month
-
Day
Year
Date
What is the date of the payment that was returned unpaid?
-
Month
-
Day
Year
Date
What was the amount of that payment?
What is the total amount past due as of the date of this notice (including unpaid rent and other charges)?
What is the daily late charge amount that must be added for each day after the notice date?
What is the deadline date by which the tenant must remit payment?
-
Month
-
Day
Year
Date
To whom and at what location must the tenant send the payment, as required by the lease?
Which payment methods are acceptable for curing the breach? (Check all that apply)
Check
Cashier’s Check
Money Order
Other
Which payment methods are required for all future payments under the lease? (Check all that apply)
Check
Cashier’s Check
Money Order
Other
If the landlord is invoking Paragraph 5D(5) of the lease due to repeated late payments, is payment by certified funds now required?
Yes
No
What is the date of the payment that was applied to non-rent obligations?
-
Month
-
Day
Year
Date
To which specific unpaid items (e.g., late fees, repairs, etc.) was this payment applied?
What is the remaining unpaid balance of rent after applying the payment?
By what date must the tenant pay this remaining unpaid balance?
-
Month
-
Day
Year
Date
On what date was the rent payment due that the tenant wrongfully withheld?
-
Month
-
Day
Year
Date
What is the total amount past due as of the date of this notice (including unpaid rent and other charges) due to wrongful withholding?
What is the daily late charge amount that must be added for each day after the notice date?
What remedies might the landlord pursue if the tenant fails to comply (e.g., termination, damages, legal fees)?
What is the name of the landlord issuing this notice?
What is the date this notice is issued by the landlord?
/
Month
/
Day
Year
Date
If signed by someone other than the landlord, who is signing on behalf of the landlord under a property management agreement or power of attorney?
What is the date of this signature?
/
Month
/
Day
Year
Date
What is the printed name of the person signing?
What is the firm name of the person signing (if applicable)?
How is this notice being delivered? (Check all that apply)
Regular US Mail
Certified Mail with Return Receipt Requested
Fax
Hand Delivered
If Other, what is the alternative delivery method?
If Certified Mail is selected, what is the Return Receipt Requested Number?
If Fax is selected, to what number or recipient was it faxed?
If Hand Delivered, to whom was it delivered, and by whom?
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