1.FAMILY-_APPLIANCES__FURNITURE.pdf

Rev Jun 15

FAMILY

APPLIANCE LOANER REQUEST

Address Delivery Date Time

Last Name First Name MI Pick-up Date Time

Rank Command Telephone Number

Appliance Allowance Requested Remarks

1. Refrigerator 1

2. Japanese Cooking Stove 1

3. Japanese Washer 1

4. Japanese Dryer 1

5. Kerosene Heater 2

6. Window A/C Heater 2

7. Dehumidifier 1

8. Smoke Detector 2

9. Transformer (Voltage converter) 2

10. CO Detector 1 per floor

11. *Microwave Oven 1

* Microwave Oven is ONLY issued when a unit cannot accommodate a stove with oven.

WINDOW A/C HEATER UNIT GAS TYPE

Yes No City Gas LP Gas

I agree to pay for damage beyond normal wear and tear, and for items missing during my occupancy, noted hereon. I must clean all appliances before pick up or I will be charged a $65 per appliance cleaning fee. ________

Tenant Signature / Date Counselor Signature / Date

<< SAMPLE >>

Rev Jun 15

FAMILY

FURNITURE LOANER REQUEST

Address Delivery Date Time

Last Name First Name MI Pick-up Date Time

Rank Command Telephone Number

Circle # of Dependents: 1 2 3 4 *Allowance is determined by the number of dependents

Item *Allowance Requested Remarks Master Bedroom

1. Double Bed Frame 1

2. Double Bed Box Spring 1

3. Double Mattress 1

4. Dresser 1

5. Mirror 1

6. Night Table 1

Additional Bedroom(s)

7. Single Bed Frame 3

8. Single Bed Box Spring 3

9. Single Mattress 3

10. Crib 1

11. Chest of Drawers 3

12. Night Table 3

Dining Room

13. Dining Table 1

14. Dining Chair 6

15. Microwave Oven (PCS out only) 1

Living Room

16. Arm Chair 2

17. Sofa 1

18. Coffee Table 1

19. End Table 2

20. Table Lamp 2 I agree to pay for damages beyond normal wear and tear, and for items missing during my occupancy, noted hereon.

I must clean all furniture before pick up. I understand that I will be charged a delivery/pick-up fee if I fail to notify the HWC two days before any schedule change or if I, or my representative, are not present at the appointed time. ______

(This applies when moving-in) I understand that the loaner furniture will be provided for up to 90 days or until the arrival of my household goods. I will return my loaner furniture not later than ____________ unless my request for a 30 day extension of loaner furniture is approved. I am aware that no partial pick-ups are allowed. _______

Tenant Signature / Date Counselor Signature / Date

<< SAMPLE >>