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(123 PRE-POP NOT WORKING LANE)
(SOMECITY, ZZ 00000-1111)
Tel: (000-000-0000)
Fax: (000-000-0000)
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Certification of Intent to Repair

To be completed by: Homeowner(s)

Fill in all required fields below *
The following fields need to be corrected:*

Loan Number: (#000000)

Date: (Month 00, 0000)

Property Address:

 

I/We hereby certify that the insurance claim
 
check number
*
in the amount of $
*
will be used to repair the (Cause of loss) damage(s) to the referenced property that occurred on (Date of loss), and that the repairs will be made in compliance with all local building codes and that no material or labor liens will be permitted against the property as a result of the labor performed or materials used.
 
 
 
 

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