REAL ESTATE COLLECTION PLACEMENT FORM Landlord ____________________ Address ________________________ Agent _______________________ Address ________________________ ************************************************************** Tenant(s)_____________________________________________________ Tenancy Address ___________________Apt# Tel # _____________ Current Address ____________________________ Tel# ____________ Place of Business__________________________Tel# ______________ Guarantor _______________________Address _____________________ Bank Accounts_________________________________________________ MONTHLY RENT $_______________ DUE FROM ____________TO_________ DAMAGES $ ______________PAINTING________________ MISC ________ (Attach copies of bills) Security $ ______________Attach cover & signature pages of lease & renewal(s) LEGAL COSTS $ ________________ Attach eviction papers if any MOVE OUT DATE ________________ Re-Rental Date ________________ S.S.#/ COMMENTS ______________________________________________ ______________________________________________________________ Please include copy of credit ap, credit report, checks, breakdown sheet and all other information which you feel may be helpful to us. by : _________________________ Date of Referral ______________ Signature/Title Your Tel # (____) ____________________ Arrears History Bldg. _________________ Apt _______ Month ____________________ 200_ $ ________________ Month ____________________ 200_ $ ________________ Month ____________________ 200_ $ ________________ Month ____________________ 200_ $ ________________ Month ____________________ 200_ $ ________________ Month ____________________ 200_ $ ________________ Total $ ________________ Security - $ ________________ Total $ ________________ Legal Fees $ ________________ Damages $ ________________ Total to Date $ ________________ If lease hasn't expired, please let us know when the apartment or space is re-rented. Please complete all forms, and include all available data.