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Form #23 : ACTUAL DAMAGES INVOICE

Required entries are indicated by blue icons or *

Tenant(s)* (required)

Tenant(s)

et al (and all others)

Property Address* (required)

Unit #

City (Oregon ONLY)

OREGON Zip Code

Owner/Agent has sustained the following damages:

Breach of Contract:

Description

Action Taken:

Description

Date Action Taken:

mm/dd/yyyy

Please Note: This form does not calculate totals.

Repair Cost

Sub-Total

Materials

Quantity

Cost

Sub-Total

Time Incurred

Hours/Minutes

Charge Per Hour

Sub-Total

Cost of Forms

# of Forms

Form Cost

Sub-Total

Copying/Printing

Quantity

Cost

Sub-Total

Total Mileage

Total Miles

IRS Mileage Rate

Sub-Total

First Class Postage

# of Stamps

Cost

Sub-Total

TOTAL DUE

Total Amount

Due Date:

mm/dd/yyyy

(30 days from date of notice)

Please Note: Signature field must be filled in and signed after printing.


Owner/Agent Signature:				Date:

MAKE PAYMENTS TO:

Owner/Agent

Address

City

State

Zip

Telephone

In accordance with Oregon Revised Statute 90.401(2): Remedies available to landlord. In addition to the remedies provided in ORS 90.392, 90.394, 90.396 and 90.398, a landlord may recover damages and obtain injunctive relief for any noncompliance by the tenant with the rental agreement or ORS 90.325 or 90.740.

Form #23 : ACTUAL DAMAGES INVOICE

Rev.4/16

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