On ______________________ (date), ___________________________________ (tenant name) paid $________________________ in: 

___ CASH
___ CHECK, NO. _____________ 
___ MONEY ORDER, NO. _______________

 for rent on _____________________________________ (address). The tenant still owes $ ______________________ (balance due after payment).

Money Received By: ______________________________________ (Landlord signature) ______________________________________ (print name)