HOUSE CHECK REQUEST FORM :: DAYTON POLICE DEPARTMENT

TO REQUEST A HOUSE CHECK, PLEASE FILL OUT THIS ONLINE FORM AS COMPLETELY AS POSSIBLE.

Address of house to be checked*

Please enter an address.

Requestor's Name*
(Name of person submiting this form.)

Please enter your name.

Requestor's Email*
(Email address of person submiting this form.)

Please enter your email address.

Home Owner's Name
(if different from Requestor)

Home Owner's Home Phone*

Please enter the Owner's Home Phone Number.

Home Owner's Cell Phone

Date Leaving* (mm/dd/yyyy)

A value is required.

Date Returning* (mm/dd/yyyy)

A value is required.

Lights left on?

Yes
No

Location of Lights Left on:

First Floor
Second Floor
Lower Level

Local Emergency Contact Person*

Please enter the name of a local emergency contract person.

Local Emercency Contact Person's Home Phone*

Please enter the phone number for the specified local emergency contract person.

Local Emercency Contact Person's Address

Local Emercency Contact Person's Alt/Cell Phone

Does Contact Have Keys?

Yes
No

Other Authorized Persons Checking the Home:

Name		Phone
Name		Phone

Vechicles that may be at residence:

License#		Make/Model		Color
License#		Make/Model		Color

Does the owner wish to be notified of a major incident?*

Yes
No
Please make a selection.

If "YES," provide phone number of where owner can be reached. If "NO," enter NA.

A value is required. If "NO," enter NA.

Additional Comments

Clicking the SUBMIT button will email the contents of this form to Police Administrative Assistant Lynn Reichstadt at

* denotes required fields.