Non-Payment Terminate Notice

Property Name

What is your tenant's full name?

What is the name of the landlord the lease agreement is with?

How much rent (in $$$) does your tenant owe?
(exclusive or late fees or other costs )

What months does the delinquent rent represent?
(i.e. January, February, etc.)

How much (in $$$) does the tenant owe in late charges?
(subject to the terms of your lease agreement)

What months do the late charges represent?
(i.e. January, February, etc.)

How much (in $$$) does the tenant owe for other charges?
( i.e. Carport, Lock-out, Damages, etc. )

What are these other charges?
(i.e. Carport, Lock-out, Damages, etc. )

Cash

Money Order

Certified or Cashiers Check

Personal Check

If the tenant has questions, who should they contact?
(if different than landlord)

What is the telephone number of the contact person above?
(if different than landlord)

A copy of this notice was delivered to Tenant:

By personal service

By registered/certified mail

By first class mail

By posting on the front door of the above leased premises

Notice delivered/posted on the

Notice delivered/posted/mailed in his/her capacity as:

Landlord/Lessor

Agent for Landlord

Create a Non-payment Notice