Date: __________________

To: __________________________ (Name of Tenant)

__________________________ (Address of Tenant)

From: ________________________ (Name of Landlord)

________________________ (Address of Landlord)

We want to make the place where you live as safe as it can be. We are constantly on the lookout for anything around your home which can prove hazardous to life, limb, or property. But as hard as we try, we cannot uncover every potential danger all by ourselves. We need your help.

Because you are around your home much more than we are you have a greater opportunity to notice hazards. Please report to us anything you notice which you think might prove hazardous to you or anyone else. We promise that we will investigate the hazardous condition if we possibly can.

Please complete the bottom section of this letter and return it to us with your next rent payment. Thank you for your cooperation in making your home a safer place to live.

� We know of nothing which appears to be unsafe in or around our home, but we will alert you whenever we do notice something.

� We would like to call your attention to the following unsafe conditions in or around our home:

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We suggest that you take the following corrective action:

Signed: ___________________________ Date: ___________________