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2. Requester's Name*
3. Requester's Phone Number*
7. Read Type*

   1. Tenant In
   2. Tenant Out
8. Effective Date*
   Effective Date

12. Owner's Information

14. Owner's Name*
15. Owner's Email Address
17. Owner's Address*
19. Owner's City*
20. Owner's State*
21. Owner's Zip Code*
23. Owner's Phone Number*
24. Owner's Cell Number

28. Tenant's Information

30. Tenant's Name
31. Tenant's Email Address
33. Tenant's Forwarding Address*
35. Tenant's Forwarding City*
36. Tenant's Forwarding State*
37. Tenant's Forwarding Zip Code*
39. Tenant's Phone Number*
40. Tenant's Cell Number

44. For Official Use Only

46. Account Number
47. Read Date
48. Read
50. TBTR Date
51. LBTR
52. Days in Cycle
54. Prior Account Balance
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56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field