Here's one you can use. Hope it helps. Pics and receipts are with you.
Security Deposit Refund Form
Date: _______________
Tenant's Name: _________________________
Address of Rental Unit: ____________________________________________________________
Total Deposit Amount Received from Tenant: $ _______________
Reason(s) for Security Deposit Deduction Amount
1. _______________________________________________________ $ _______________
2. _______________________________________________________ $ _______________
3. _______________________________________________________ $ _______________
4. _______________________________________________________ $ _______________
5. _______________________________________________________ $ _______________
Total Amount of Security Deposit Deductions: $ ______________
Security Deposit Interest Payable to Tenant: $ _____N/A_______ (if applicable)
Total Amount of Security Deposit Returned: $ _______________
As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your rental obligations.
Landlord’s Signature: _________________________
Landlord's Name: _________________________
Modify it to your needs.
--77.31.xx.x