Leesburg Police Department
House Check Request Form
This form is used to communicate with the Leesburg Police Department if you wish to schedule a security check of your residence while you are away.
NOTE: Please do not use this form to report emergency issues or for conditions requiring immediate response. If you have an emergency, please use the telephone and call 9-1-1.
Your Name:
Your Email:
Property Owner's Cell Phone:
Property Owner's Phone:
Property Address:
Departure Date:
Return Date:
Is the property protected by a security system?
Will any lights be left on at the property?
Please list detail information about lights left on:
Will any vehicles be left on the property?
Plese list detailed information about vehicles,
including make, model, color and license plate #:
Does anyone have permission to be on the property in your absence:
Names and Phone numbers of people
with permission to be on the property:
Are you leaving keys to the property with anyone locally?
Names and Phone numbers of people with keys to the property:
Will the key holder know how to reach you in the event of an emergency?
Your emergency phone number:
