Semi-Annual Safety and Maintenance Update

Please complete the following checklist and note any safety or maintenance problems in
your unit or on the premises.
Please describe the specific problems and the rooms or areas involved. Here are some
examples of the types of things we want to know about: garage roof leaks, excessive
mildew in rear bedroom closet, fuses blow out frequently, door lock sticks, water comes
out too hot in shower, exhaust fan above stove doesn't work, smoke alarm malfunctions,
peeling paint and mice in basement. Please point out any potential safety and security
problems in the neighborhood and anything you consider a serious nuisance.
Please indicate the approximate date when you first noticed the problem and list any
other recommendations or suggestions for improvement.
Please return this form with this month's rent check. Thank you. -- THE
MANAGEMENT

Name: ______________________________________________
Address: ____________________________________________

Please indicate (and explain below) problems with:

[ ] Floors and floor coverings ______________________________________
[ ] Walls and ceilings ____________________________________________
[ ] Windows, screens and doors ____________________________________
[ ] Window coverings (drapes, mini-blinds, etc.) ________________________
[ ] Electrical system and light fixtures ________________________________
[ ] Plumbing (sinks, bathtub, shower or toilet) __________________________
[ ] Heating or air conditioning system ________________________________

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Semi-Annual Safety and Maintenance Update

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[ ] Major appliances (stove, oven, dishwasher, refrigerator) _______________

[ ] Basement or attic _____________________________________________
[ ] Locks or security system _______________________________________
[ ] Smoke detector ______________________________________________
[ ] Fireplace ___________________________________________________
[ ] Cupboards, cabinets and closets _________________________________
[ ] Furnishings (table, bed, mirrors, chairs) ____________________________
[ ] Laundry facilities ____________________________________________
[ ] Elevator ___________________________________________________
[ ] Stairs and handrails __________________________________________
[ ] Hallway, lobby and common areas _______________________________
[ ] Garage ____________________________________________________
[ ] Patio, terrace or deck _________________________________________
[ ] Lawn, fences and grounds _____________________________________
[ ] Pool and recreational facilities __________________________________
[ ] Roof, exterior walls and other structural elements ___________________
[ ] Driveway and sidewalks _______________________________________
[ ] Neighborhood _______________________________________________
[ ] Nuisances __________________________________________________
[ ] Other ______________________________________________________

Specifics of problems:
_____________________________________________________________
_____________________________________________________________

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_____________________________________________________________
_____________________________________________________________

Other comments:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________________________________________________

Date: ________________
Tenant: ______________________________________________________
----------------------------------------------------------------------------------------------------FOR MANAGEMENT USE
Action/Response:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Date: ____________________
Landlord/Manager: ____________________

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