RUSSIAVILLE POLICE DEPARTMENT
SECURITY CHECK

Name_______________________________   Address__________________________________

Phone___________________  Date of Departure _______________  Return ________________

In case of Emergency, Notify ______________________________  Phone __________________

Does this person have a key? ________

List any other persons authorized to be at the residence during your absence,

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Vehicles on property during absence, including authorized persons and yours,

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

List any lights left on, lights on timers, etc.

____________________________________________________________________________

____________________________________________________________________________

Return this form to:
Russiaville Police Department
P.O. Box 278
Russiaville, IN 46979

Or;
Drop off to Linda Downey at the Town Hall

Thanks for your cooperation,

Roger L. Waddell, Marshal