2.SINGLE_-_APPLIANCES__FURNITURE.pdf

Rev Jun 15

SINGLE

APPLIANCE LOANER REQUEST

Address Delivery Date Time

Last Name First Name MI Pick-up Date Time

Rank/Rate Command Telephone Number

ROOMMATE:

Last Name First Name MI Pick-up Date Time

Rank/Rate 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 1

6. Window A/C Heater 1

7. Dehumidifier 1

8. Smoke Detector 1

9. Transformer 1

10. CO Detector 1

11. * Microwave Oven 1

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

WINDOW AIR CONDITIONER 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. 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. ______

Tenant Signature / Date Counselor Signature / Date

Roommate Signature / Date

<< SAMPLE >>

Rev Jun 15

SINGLE

FURNITURE LOANER REQUEST

Address Delivery Date Time

Last Name First Name MI Pick-up Date Time

Rank/Rate Command Telephone Number

ROOMMATE:

Last Name First Name MI Pick-up Date Time

Rank/Rate Command Telephone Number

Item Allowance Requested Remarks 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

Dining Room

7 Dining Table 1

8 Dining Chair 2

Living Room

9 Arm Chair 1

10 Love Seat 1

11 Coffee Table 1

12 End Table 1

I agree to pay for damage 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

Roommate Signature / Date

<< SAMPLE >>