Request For Residential Vacation Checks Form
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3Madison County Sheriff’s Office
Office Use Only
546 East College St. Jackson, TN 38301
731-423-6000
District #____________
ID #________________
Request for Residential Vacation Checks
(Two weeks maximum)
If you live in Madison County, and would like to have vacation checks performed on your residence, please complete this form
and submit to Madison County Dispatch at least 48 hours prior to your planned absence. (Please Print-Fill-a-ble Form)
Personal Information
Name: ________________________________ Residence Address: ___________________________________
Date of Birth: ______ / ______ / ______
Phone: ______________________________ Email Address: ________________________________________
Date Leaving: ______ / ______ / ______ Date Returning: ______ / ______ / ______
Papers/Mail/Deliveries Stopped?☐YES ☐NO
Will any lights be left on? ☐YES ☐NO
Will lights be on a timer? ☐YES ☐NO
If lights on, which rooms?
_____________________________________
(Example: front hallway, back bedroom, etc.)
Pets? ☐YES ☐NO
Type: ___________________ ☐Indoor ☐Outdoor
Who will be caring for the animal(s)? ____________________________ Phone: ________________________
Does anyone have your permission to be on your premises?☐YES ☐NO
If yes, who? ____________________________ Phone: ________________________________________
Vehicle Information
(Vehicles to be at the residence)
Year: _______ Make: ____________ Model: ________________ Color: ___________ Plate: ______________
Year: _______ Make: ____________ Model: ________________ Color: ___________ Plate: ______________
Year: _______ Make: ____________ Model: ________________ Color: ___________ Plate: ______________
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