Keep Check

Date Leaving:       Date Returning:

Time Leaving:   Time Returning:  Type:

Name:  Street Address:  

Main Contact Number:  Secondary Contact Number:

Alarm :  Alarm Company:

Alarm/Key Holder/Contact Person: List all names and contact numbers 

Light(s) left on or on timers (list areas): 

Vehicles left in driveway, around house, or allowed on property during vacancy:

Pets on Property:  Dangerous:

Type of Pets:

Persons allowed around residence or looking after property: (List all names and contact numbers)

Statement of Limited Liability:  It is hereby understood that in consideration for the Newton Police Department keeping check on my/our property that I/we hereby release the Newton Police Department from any liability from loss or damage to my property.  By submitting this form you understand/agree to the limited liability clause and agree to receive a preliminary phone call from the Newton Police Department to check the validity of this request. 


_______________________Office Use Only______________________________


Special Observations:______________________________________________________ 



Supervisor's Initials:__________________________________