Town of Kersey

Vacation Request

If you live within the Town of Kersey and would like to have vacation checks performed on your residence, please complete this form and submit it to the Kersey Town Hall. You must notify the Police Department immediately if the departure or return dates and times change.

Name

Date of Request

Phone

Residential Address

City

State

Zip Code

Date & Time Leaving

Date & Time Returning

Location & Phone Number of Where You Are Staying

Describe any vehicles to be left on your property with plate numbers

Do you have an alert system?

Yes

If monitored, company name and phone:

Are there any indoor or outdoor lights to be left on?

Yes

Where are they located and when do they turn on/off?

Are there any pets to be left on your property?

Yes

Are services to be suspended while you are gone?

Yes

Person(s) allowed on the property while gone (please include addresses and phone numbers):

The undersigned does hereby grant and request that the Kersey Police Department visually check the property listed above, which may include access to the yard. The undersigned does hereby agree to hold harmless the Town of Kersey, its employees and agents for any claim for personal injury, loss or damage to property that may be suffered by the undersigned or other agents of the undersigned, through any action or lack thereof, by representatives of the Town of Kersey. Further, the undersigned understands and agrees that this is a voluntary free service and does not create a special duty upon the Town and will be provided only as time and personnel are available and no guarantee is made or assurance given against loss, theft or damage to property.

Signature of homeowner / renter / leasee

Date