MONTGOMERY COUNTY MUNICIPAL COURT
CIVIL DIVISION
APPLICATION BY TENANT TO DEPOSIT RENT IN ESCROW
TO THE CLERK OF COURTS CASE NO:
Tenant: Landlord:
______________________________ ____________________________________
______________________________ ____________________________________
______________________________ ____________________________________
______________________________ ____________________________________
In accordance with Section 5321.07, Para. (1) of the Ohio Revised Code, I hereby make application to deposit all
rent that is due and hereafter becomes due the landlord, with the Clerk of the Montgomery County Municipal
Court.
______________________________
Tenant
INFORMATION IN SUPPORT OF APPLICATION
The undersigned says the following facts are true to the best of their knowledge. Notice was given in writing to
the landlord as prescribed in Section 5321.07, para. (A) with a copy of the notice attached hereto.
Service was made on the landlord as follows: _____________________________________________________
That payment of my rent due under the rental agreement is current and that my rent is due
on_________________________ in the amount of $______________.
Is it stated in your rental agreement, or did the landlord supply you with a notice in writing that the landlord is a
party to rental agreements that cover three or fewer dwelling units?
Circle One: YES or NO
APPLICANT STATES UNDER THE PENALTIES OF PERJURY AND FALSIFICATION THAT THE
ABOVE INFORMATION AND APPLICATION HAS BEEN READ AND IS BELIEVED TO BE TRUE.
______________________________
Applicant Signature
_________________________________________________________________________________________
NOTICE TO LANDLORD OR AGENT
Sec. 5321.08 R.C.
Please be advised that the above applicant has deposited a rental payment with the Montgomery County Municipal
Court Clerk’s Office pursuant to O.R.C. 5321.07. The deposit has been placed in the Escrow Rental Account and
may be released to you upon your application and satisfaction of the provisions of O.R.C. 5321.09.
Date: _________________ Montgomery County Clerk of Courts
_______________________________
Deputy Clerk