Application regarding unpaid rent

Régie
du logement
Application regarding unpaid rent
Annex attached to add additional;
information regarding the object or grounds of the application
parties to the application
ADDRESS OF DWELLING IN QUESTION (Press hard when writing)
N°
Street
N° de la demande
Apt.
Municipality
Postal code
Code du recours
Conciliation offerte
1971 TS
1863 R
Conciliation acceptée
Municipalité
Avis d'audition expédié
Code du préposé
DESCRIPTION OF PARTIES (Write in capital letters)
Defendant
Lessee
Plaintiff
Lessor
(Complete address, if different than that of the dwelling in question)
Family name (1)
Family name (1)
First name
First name
N°
Street
Municipality
Home telephone no.
Apt.
N°
Postal code
Municipality
Work telephone no.
Street
Postal code
Home telephone no.
Family name (2)
Family name (2)
First name
First name
N°
Street
Municipality
Home telephone no.
Apt.
Apt.
N°
Postal code
Municipality
Work telephone no.
Work telephone no.
Street
Apt.
Postal code
Home telephone no.
Year
Beginning
of
lease
OBJECT AND GROUNDS OF THE APPLICATION
Resiliation of the lease and eviction of the lessee
Month
Day
Work telephone no.
End
of
lease
Year
Month
Day
Monthly
rent
$
Recovery of rent due at the time of the hearing
The payment of rent has not been made for the following period :
$
$
$
Jointly and severally
Interest and the additional indemnity provided for in the Civil Code
Payment of costs
Provisional execution of the decision notwithstanding appeal
The lessee has delayed payment of the rent for more than three weeks.
AVIS D'AUDITION
Veuillez vous présenter le
Année
à
Date de production
Mois
au
Jour
h
Application signed on
2009/03/04
Date
Signature
I acknowledge receipt of the present notice of hearing.
Date
Rôle
Bur.
N°
Régie du logement
Séquence
Signature
Type
An
Mois
Jour
Date
RDL-065A-E (04-02)