*Address:
House Description:

*Home Phone: Cell Phone: Work Phone:

Email Address:

*Date of Vacation
Leaving: Return:
If longer than two weeks, please call the Police Department directly.

*Local Emergency Contact
Name: Phone:
Must be local contact, can list multiple if needed

*Animals left at residence (include type and location of pets):

If dogs are on property and outside, patrols will NOT be conducted in backyards/within fenced areas.

*Vehicles left at residence (including garage, give description):

*Lights left on at residence or on timers (inside and outside):

*Alarm system: Yes
If yes, please give local contact information incase of alarm activation:

*Persons allowed on property and vehicle descriptions:

Include maid services, ground keepers, family members not traveling, etc.

Mail/newspaper service canceled: Yes No

Prior crime victim/threats made: Yes No
If yes, type of crime and suspect information if available

Any additional information you would like to share:

For verification, please type the characters you see in the picture below.

I agree as a condition of submission to release, defend, indemnify and hold the City of South Jordan, its officers, agents, employees and volunteers harmless from and against any and all loss, judgments, damages, or expenses, arising from or incurred by reason of any claim, lawsuit or action in law or equity, based upon property damage or theft to the property listed on this submission, except to the extent that such injury or damage is directly caused by the negligent acts or omissions of the City of South Jordan, its officers, agents, employees or volunteers resulting from my request for this service.