LAKEWOOD MUNICIPAL COURT APPLICATION BY TENANT TO DEPOSIT RENT NAME AND ADDRESS OF LANDLORD OR AGENT: Case No._____________________________ NAME AND ADDRESS OF TENANT: _______________________________________________ (name) _______________________________________________ (street address) ____________________________________________ (name) ____________________________________________ (street address) ____________________________________________ (city, state zip) _______________________________________________________ (phone) _______________________________________________ (city, state, zip) ___________________________________________________________ (phone) In accordance with Section 5321.07 (B) and (B) (1) of the Ohio Revised Code, I hereby make application to deposit all rent that is due and hereafter becomes due the landlord, with the Clerk of Lakewood Municipal Court. DATE: _____________________ SIGNED: ___________________________________________ AFFIDAVIT IN SUPPORT OF APPLICATION: The undersigned, being first duly cautioned and sworn or affirmed, according to law, says the following facts are true to the best of his knowledge: 1. Landlord did NOT supply him with notice in writing that he was a party to any rental agreement, which covered three or fewer dwelling units. (Ohio Revised Code Section 5321.07 (C)). 2. Notice was given in writing to landlord as prescribed in Ohio Revised Code Section 5321.07 (A). (Copy of this notice is attached hereto.) Service was made on the landlord as follows: __________________________________________________________. That payment of my rent due under the rental agreement is current and that my rent is due ____________________________________, in the amount of $ ___________. (Ohio Revised Code Section 5321.07 (B)). Signed: _____________________________________________ Sworn to before me and signed in my presence this _________ day of _________________________________, 20_____ TERRI A. O'NEILL, CLERK OF COURT ______________________________________ Deputy Clerk NOTICE TO LANDLORD OR AGENT: In accordance with Ohio Revised Code Section 5321.08, you are hereby notified that the above tenant has deposited with the Clerk of the Lakewood Municipal Court rent due by him/her on the above- described premises. THIS IS A COPY OF TENANT'S APPLICATION TO: _____________________________________ _____________________________________ _____________________________________ DATE MAILED:__________________________ TERRI A. O'NEILL, CLERK OF COURT ______________________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com 3. Rev. 2/4/2016