House Check Form

Name:

Address:

Date Leaving:

Date Returning:

Home Phone (no spaces) : Cell Phone (no spaces) :

Emergency Contact Person:

Emergency Contact Number (no spaces) :

Does the emergency contact have a key? Yes No

Do you have an alarm system Yes No

If yes, alarm company name:

Alarm Contact Number (no spaces):

List what lights will be left on (kitchen, living room, hallway, bedroom):

Will there be any outside lights left on? Yes No

Are the outside lights on timers? Yes No

Are the outside lights motion activated? Yes No

Do you have any broken doors, windows, or torn screens? Yes No

If yes, location:

Will you stop newspaper and mail delivery? Yes No

If no, is someone collecting them for you? Yes No

Are there pets in the house or yard? Yes No

If yes, type of pet:

Pet Care Contact Number (no spaces) :

Describe vehicles or propety left outdoors while on vacation:

Vehicle #1
Make: Model: Color:
Year: License Number: State:

Vehicle #2
Make: Model: Color:
Year: License Number: State:

Please read:
By submitting this form, you do hearby grant and request the village of Timberlake and the Police Department to visually chcek upon the property listed above. You agree to hold harmless the Village of Timberlake, its employees, and agents for any claim of personal injury, loss or damage to property that may be suffered, through any action or lack thereof, by a representative of the Village of Timberlake. Further, you understand and agree that this is a voluntary, free service and does not create a special duty upon the Village, will be provided only as time or volunteer personnel is available, and no guarantee is made nor assurance given against loss, theft, or damage to premesis.