Summit Police Department
512 Springfield Avenue
Summit, N.J. 07901
Phone: 908-273-0051  Fax: 908-273-8002

Unoccupied Building Report

Name of Resident: _______________________________________

Address: _________________________________________________________

Vacant:   From: _____/______/20____         To: _____/_____/20____

Premises is Furnished (   )          Unfurnished (   )

Is Premises Alarmed:   Yes (  )    No (  )

Is Resident Deceased:  Yes (  )    No (  )

Have Mail, Paper etc Deliveries been cancelled:  Yes (  )  No (  )

Person for Police to contact locally:  Name: _________________________________________

                                                       Phone: _________________________________________

Keyholder if different from above:    Name: _________________________________________

                                                       Phone: _________________________________________

Resident's Phone Number while away if known: ______________________________________

                                                       Cell Phone: ______________________________________

Where staying if known: ________________________________________________________

Date Recieved: ____/____/20___                                                        Area _________________

                   Please notify the Police when you return or if premises will be occupied.