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Revised 11/22/2002 No. Date: Homeowner: Phone: Address/Location: Date Leaving: Date Returning: Inside Lights: No Yes (if yes indicate location and if on timers) Location of lights: Keys With: Name: Address: Phone They will be checking your home? No Yes Vehicles: Location: Description: Visible Property damage: Other Information: Please come to the Moscow Police Department and advise us of your return. Thank you. If you would like an officer to accompany you through a Home Security check of your residence, check the following: Home Check: House Checks: MOSCOW POLICE DEPARTMENT HOUSE CHECK Moscow Police Department Use Only Home Security check completed by Date: Report provided to homeowner by: Date: Copy of report must be attached to this notice. Officers Name Date Time Officers Name Date Time Print Form Fax to [PHONE REDACTED]