Maintenance & Repair Request Form

OREGON

M INTEN NCE & REP IR REQUEST

D TE

PROPERTY N ME / NUMBER

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RESIDENT N ME(S)

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UNIT NUMBER

STREET DDRESS

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CITY

ST TE

ZIP

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SAMPLE

SAMPLE

SAMPLE

BEST W Y TO CONT CT ME: PHONE

TIMES:

TO

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SAMPLE

SAMPLE

EM IL

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SAMPLE

SAMPLE

SAMPLE

SAMPLE

X

X

X

X

ENTRY CONCERNS: MINORS

YES

NO

PETS

YES

NO IF YES, NUMBER & TYPE

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SAMPLE

OTHER ENTRY CONCERNS

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SAMPLE

TYPE OF MAINTENANCE OR REPAIR NEEDED:

SAMPLE

X

X

X

X

X

X

Heating

Appliance

Doors / Windows

Plumbing

Electric

Other

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Exact nature of problem and cause (if known). Be SPECIFIC!

SAMPLE

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Resident agrees that this written request authorizes Owner/Agent to enter the Premises without notice at reasonable times to perform the

repairs/maintenance. This authorization expires after seven (7) days unless the repairs/maintenance are in progress and Owner/Agent is making

reasonable effort to complete the repairs/maintenance, in which event Resident authorizes entry at reasonable times in excess of seven (7) days

until such repairs/maintenance are completed.

By signing this request, Resident also agrees that Owner/Agent’s staff may conduct a preventative maintenance inspection while in the unit and,

to the extent practical, do any necessary repairs. If it is not practical to perform the repairs in conjunction with the repairs requested by Resident

under this Maintenance & Repair Request, a new notice of entry will be given for the new repair work.

X

RESIDENT

D TE

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SAMPLE

OWNER/AGENT’S RESPONSE:

SAMPLE

SAMPLE

The repairs/maintenance requested above were performed on:

by:

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The following work was completed:

SAMPLE

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SAMPLE

SAMPLE

X

X

Smoke Alarm(s) checked Date

Carbon Monoxide Alarm(s) checked (if applicable) Date

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X

OWNER/ GENT

D TE

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ON SITE

RESIDENT

M IN OFFICE (IF REQUIRED)