Receipt of S ecurity Deposit
Date: ___________________________
Tenant's Name: ___________________________________________________________________
The Landlord/Landlord's Agent hereby acknowledges payment in the amount of $____________, not
to exceed four (4) weeks rent, from the above Tenant for the security deposit for the rental premises
located at:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
The above rental premises is owned by _________________________________________________
(insert name of legal owner of rental premises) whose address is:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_______________________________________
(Landlord/Owner or Landlord's Agent Signature)
Please note that this document is for reference purposes. You may wish to check with your local landlord
association or obtain legal advice to make sure information is appropriate for your state.