You are hereby notified that there is now due to the undersigned landlord the sum of____________
dollars being rent for the premises located in__________________, County of____________________,
and State of___________, described as follows:__________________________________________________
And you are further notified that payment of said sum so due has been and is hereby demanded of
you, and that unless payment thereof is made on or before the expiration of five (5) days after
service of this notice, your lease of said premises will be terminated.
Only FULL PAYMENT of the rent demanded in this notice will waive the landlord's right to
terminate the lease under this notice, unless the landlord agrees, in writing, to continue the
lease in exchange for receiving partial payment.
Dated this___day of__________,20_____.
Landlord/Managing Agent Address
AFFIDAVIT OF SERVICE - When served by a person not an officer
____________________________, being duly sworn, on oath deposes and says that on the______day of
____________,20___he/she served the within notice on the tenant named as follows:*
____ (1) by delivering a copy thereof to the within named tenant,_______________________________.
____ (2) by delivering a copy thereof to___________________________________,person above the
age of ten years, residing in or in charge of the within described premises.
____ (3) by sending a copy thereof to said tenant by** registered/certified mail, return receipt
____ (4) by posting a copy thereof on the main door of the within described premises, no one
being in actual possession thereof.
*Check off all applicable paragraphs. ________________________________________________
** Strike out word not applicable. Signature of Notice Server
My Commission expires_____________20___.