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2. Type of Check

   1. Vacation

   1. Vacant

   1. Other
4. Owner Name*
5. Address*
6. Phone
8. Emergency Contact
9. Phone
11. Date / Time Gone
    Date / Time Gone Start Date

    Date / Time Gone Start Time

    —

    Date / Time Gone End Date

    Date / Time Gone End Time
13. Lights on?

    1. Yes
    2. No
14. If yes, where are lights located?
16. Lights on timers?

    1. Yes
    2. No
17. If yes, when is their cycle?
    If yes, when is their cycle? Start Time

    —

    If yes, when is their cycle? End Time
21. Vehicles in Driveway
23. Make
24. Model
25. Color
27. Make
28. Model
29. Color
33. Keys Left With
35. Address
36. Phone
38. Additional Information
40. By recording this information the Police Department does not imply or infer the acceptance of a duty for the security of the listed property. This listing is not an agreement by the Police Department to physically check the property on a predetermined regular or irregular schedule.
42. Signature of Owner
43. Date
    Date
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field