SECURITY DEPOSIT RETURN / REFUND 
TO: ____________________________________ (Former Tenant) 
PROPERTY ADDRESS: ______________________________ UNIT #: ______  CITY: _________________ STATE: _________________ ZIP CODE: _________________ 
SECURITY DEPOSIT: $_______________ 
INTEREST DEPOSIT: @ ______% $_______________ 
TOTAL SECURITY DEPOSIT: $_______________ 
RENT DUE FROM: _______________, 20___ TO: _______________, 20___: $______________ LATE FEES DUE: $_______________ 
CLEANING: $_______________ 
PAINTING: $_______________ 
CARPETS: $_______________ 
BLINDS/WINDOW COVERINGS: $_______________ 
OTHER: $_______________ 
TOTAL CHARGES: $_______________ 
BALANCE DUE OWNER: $_______________ 
BALANCE DUE RESIDENT: $_______________ 
PLEASE REMIT YOUR CHECK FOR BALANCE DUE, IF ANY, TO: 
NAME: _________________ ADDRESS: ______________________________ CITY: _________________ STATE: _________________ ZIP CODE: _________________ 
LANDLORD’S SIGNATURE: ______________________ DATE: _________________
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