Chesterfield Twp. Police Department
Check of Premises Request

Please complete this form in it's entirety. 

Today's Date:

Name:   
Address: 
Your Phone Number: 

Reason for Request:  Vacation      Emergency    Other
Date that you are leaving: 
Date that you are returning: 

In Case of Emergency Contact:  Name: 
Address:     
Telephone Number: 

Check if Premise is a Residence:
Is anyone checking your house other then the Police: Yes   No
If so, Name of Person:
Address:
Phone Number:
Any Vehicles Left on the Premises: Yes  No
If so, describe (Make, Model, Color, Registration Number) :
Any lights left on: Yes  No
Are they on a timer: Yes  No
What time do they turn on and off:  On at:
Off at:
Any Firearms left in the house: Yes  No
How many:   
In what room: 

Check if Premise is a Business:  Yes  No
Will Business be posted as being closed:  Yes  No
Any lights left on: Yes  No
Are  lights on a timer: Yes  No
If so, what time do they turn on and off  On at: 
Off at: 

Alarm Information:
Name of Alarm Company: 
Telephone Number of Alarm Company: 

Additional Comments or Information: