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FORM #30 - Deposit to Hold Agreement

  • Name(s):
  • Rental Address: Unit:
  • Applicant Mailing Address:
  • City: State: Zip:


Owner/Agent has received the sum of $ , which will be applied to amounts due at move-in.

Monthly rent to be $ (payable in advance)

Move-in date: _______________________

___ Month to Month Tenancy or ___ Fixed Term Rental Agreement
If Fixed Term is checked, lease will end on: _______________________

Security Deposit $
Other Deposits + $
1st Month's Rent + $
Subtotal = $
Minus Deposit to Hold - $
total Due at Move-In = $

___ If checked, Renter’s Insurance is required – Tenant is also required to maintain minimum of $100,000 liability coverage and add Owner/Agent as Interested Party. If Tenant(s) combined household income falls at or below 50% of the median for the area, Renter’s Insurance may not be required.

___ If checked, there are move-in or move-out fees that are associated with this unit that shall be Tenant’s responsibility to pay to Owner/Agent within 30 days once the bill is assessed by the HOA or COA. The current fees are: $ _____________.

___ If checked, the mail receptacle associated with the dwelling unit is a locking type. Tenant(s) are solely responsible for the fees charged by the Postmaster for the re-keying of the box should a key not be provided by the Owner/Agent, or if the mail box has not be re-keyed between tenancies.

If checked, there is a monthly utility charge associated with this unit. After assessment of monthly charge, Tenant(s) shall have 30 days to pay the charge in full. Failure to pay the utility charge by due date shall result in a $50 non-compliance fee

In Addition, the Owner/Agent may charge the following noncompliance fees:

  • Late payment of rent charge of $ __________
  • Smoke alarm and carbon monoxide alarm tampering fee of $250.00.
  • Dishonored check fee of $35.00 plus amount charged by bank.
  • Early termination of lease fee not to exceed 1-1/2 times the monthly rent, or actual damages at option of Owner/Agent

Owner/Agent may charge the following non-compliance fees after first giving a written warning notice of initial violation if noncompliance occurs within one year: $50.00 fee for 2nd violation, and $50 plus 5% of current rent for each subsequent violation. 1. Late payment of utility charge fee. 2. Failure to clean up pet waste, garbage, rubbish or other waste fee. 3. Parking violation or other improper use of vehicle fee. 4. Smoking in a clearly designated non-smoking unit or area of the premises fee.

  • Additionally, Owner/Agent may charge a fee for keeping on the premises an unauthorized pet capable of causing damage, that is not removed within 48 hours of written warning notice. Fee not to exceed $250 per violation.
  • Owner/Agent may charge a fee for smoking/vaping in a clearly designated non-smoking/vaping unit or area of the property. Fee may be assessed for repeat violations that occur as early as 24 hours after the effective date of a written warning notice, and for each subsequent violation within one year. Fee not to exceed $250 per violation.


It is agreed that Tenant shall pay the balance of funds due by the date the property is to be occupied, and sign a rental/lease agreement.

Owner/Agent is charging this deposit for the purpose of securing the execution of a rental agreement after having approved the application and prior to entering into a rental agreement. If a rental agreement is executed, the Owner/Agent shall apply the deposit toward the funds due under the rental agreement. If a rental agreement is not executed due to a failure by the applicant to comply with this agreement, the Owner/Agent may retain the deposit in full. If a rental agreement is not executed due to a failure by the Owner/Agent to comply with this agreement within four (4) days the Owner/Agent shall return the deposit to the applicant either at the place of business or by mailing the deposit by First Class mail to the applicant. Proof of timely compliance with this requirement shall include a postmark.


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1462 Commercial St. NE, Salem, OR 97301
Phone: 503-364-5468 | Fax: 503-585-8119

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