Free rent receipt 35
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Department of Workforce Development
Division of Vocational Rehabilitation

State of Wisconsin

Rent or Security Deposit Receipt
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].
Name of Renter
Check here if your landlord will not sign your receipt and attach a copy of your canceled check
or a copy of the face of your money order payable to the landlord.
To Be Completed by Landlord or Authorized Representative:
I received $_____________________



Security Deposit

Amount Received

For the month of ____________________________________________________
Signature (by hand) of Landlord or Authorized Representative

DVR-13814 (R. 11/2003)

Date Signed