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What is the full address of the property referenced in the residential lease?
What are the full names of the tenant(s) entering into this agreement?
What specific itemized amounts (e.g., rent, late fees, other charges) has the tenant failed to pay under the lease? (Provide a detailed list.)
As of what specific date is the total past due amount calculated?
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Month
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Day
Year
Date
What is the total amount that is past due as of the specified date?
What is the first payment amount the tenant agrees to pay, and by what specific date must it be paid?
What is the second payment amount the tenant agrees to pay, and by what specific date must it be paid?
What is the third payment amount the tenant agrees to pay, and by what specific date must it be paid?
Where is the designated place (e.g., address or person) where rents and these past due amounts are due under the lease?
Are there any additional amounts or specific lease provisions the tenant must comply with beyond the past due amounts?
Has the landlord already commenced an eviction proceeding?
Yes
No
If not, does the landlord plan to file an eviction proceeding?
Yes
No
What is the name of the landlord signing this agreement?
What is the date the landlord signs this agreement?
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Month
/
Day
Year
Date
What is the name of the tenant signing this agreement?
What is the date the tenant signs this agreement?
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Month
/
Day
Year
Date
If there are multiple tenants, what are the names and signature dates for each additional tenant?
If signed by someone other than the landlord, who is signing on behalf of the landlord under a written property management agreement or power of attorney?
What is the printed name of the person signing?
What is the firm name of the person signing (if applicable)?
What is the date of this proxy signature?
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Month
/
Day
Year
Date
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