Portage Police Department Vacation / Vacant House Request
PLEASE READ THIS FORM COMPLETELY
WAIVER
I, the undersigned, affirm I am the owner of the property indicated and further agree to hold harmless the City of Portage and the City of Portage Police Department and its employees; acknowledging that by completing this form, I am requesting police check said property during my absence. Further, I affirm the property will be vacant during the times listed below.

I further acknowledge this form in no way binds nor implies the Portage Police Department will be responsible for the security and safekeeping of my property. I understand if the police department finds an open door, officers will enter my residence and check it.
Effective Start date *
MM
/
DD
/
YYYY
End date *
MM
/
DD
/
YYYY
Address *
Your answer
Owner ( First MI Last ) *
Your answer
Phone home / work / cell *
Your answer
Email *
Your answer
Request made by ( full name ) *
Your answer
Type of property *
Lights ( Check all that apply) *
Required
Light locations *
Your answer
Please list at least two (2) key holders address and phone numbers *
Your answer
Where can you be reached, phone number and address while gone *
Your answer
Any other additional information
Your answer
You have read and understand the waiver *
Submit
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