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 $_____________________
For the month of ____________________________________________________
Signature (by hand) of Landlord or Authorized Representative
DVR-13814 (R. 11/2003)