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Statesville Police Vacation Check Request Form

Statesville Police Department

Vacation House Check Request Form


As a service to our citizens, the Statesville Police Department offers free vacation house checks for city residents who are living in single‐family homes or duplexes. These checks include a perimeter check, physical and/or visual check of all doors and windows, verification of vehicles left on the property, and verification of any persons found on the property. A log is kept of what activity was conducted on your property while you are away. Your Emergency Contact will be notified if an Officer locates evidence of unauthorized activity on the property.

*Denotes required field

*First Name: 

*Last Name: 

*Phone Number: 

*E-Mail Address: 

*House Address: 

*Emergency Contact Person: 

*Emergency Contact Phone Number: 

Keyholder Available to Respond to Location?  No   Yes

Keyholder Name & Phone Number: 

*Date of Departure: 

Time of Departure: 

*Date of Return: 

Time of Return: 

List Persons Authorized to be on Property:

List Vehicles Left on Property:
(List location and identifying information - make/model/year, color, license plate)

*Alarms: (Ctrl + Click to select multiple items)


If "Other", Please Describe:

Alarm Company: 

Existing Damage to Exterior Windows/Screens/Doors?  No   Yes (please describe below)

If Yes, please describe existing damage:


Mail Stopped?   No   Yes

Newspaper Stopped?   No   Yes   Not Applicable

Rear Yard Locked?   No   Yes  

Pets In Yard?   No   Yes (if yes, please describe below)

If yes, please describe:

If you need to provide any additional relevant information:

Please be sure to contact Statesville Police Department when you have returned home and no longer need our Vacation Check Service.  You can request a copy of the Property Check Log form upon your return.

*Property Owner Authorized Name: 

By submitting this form, listing, and entering your name, you understand that Vacation House Checks will be performed as time and personnel permits.  Entering your name into the signature field below will act as a valid signature and releases the City of Statesville Police Department of all liability for loss of property or damage occurring during this time period.  

*Authorized Signature: 

*Signature Date: 


When you press submit, you will receive an email confirmation of your submission along with a copy of the information entered. 

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