FRANKLIN COUNTY MUNICIPAL COURT
Lori M. Tyack, Clerk
Rent Escrow Division
375 South High Street, 3
rd
Floor
Columbus, Ohio 43215
(614) 645-7420
(614) 645-0474 (fax)
www.fcmcclerk.com
RENT ESCROW CASE # CVR
Name and address of TENANT Name and address of LANDLORD
(Please PRINT legibly) (Please PRINT legibly)
Telephone # ( ) Telephone # ( )
APPLICATION TO DEPOSIT RENT WITH THE CLERK
In accordance with the Ohio Revised Code Section 5321.07, I hereby make an application to deposit all rent that is due,
and hereafter becomes due the landlord, with the Franklin County Municipal Court Clerk.
Rent payment according to the rental agreement is $ , due on the of each month. This deposit is for the
month of .
Affidavit in support of Application:
The undersigned, being first duly cautioned and sworn, according to law, states that the following facts are true to
the best of his/her knowledge.
In accordance with ORC 5321.07 (C); the landlord did not provide notice, in the rental agreement, stating that
he/she was party to rental agreements that cover three of fewer dwelling units; nor did he/she, in the case of an oral tenancy,
deliver written notice of this fact to the tenant at the time of initial occupancy by the tenant. The dwelling unit is not a
private college or a university dormitory.
In accordance with ORC 5321.07 (A), the tenant has given notice of the landlord’s failure to fulfill obligations
imposed upon him/her by section 5321.04, or any obligations imposed upon him/her by the rental agreement, or the tenant
reasonably believes that the landlord has failed to fulfill any such obligations, or non-compliance citations by a governmental
agency to the place where rent is normally paid.
In accordance with ORC 5321.07 (B), the tenant is current in rent payments due under the rental agreement.
Tenant Signature
Sworn to before me and signed in my presence this day of , .
or by
Notary Public Deputy Clerk
Preferred mediation start time (circle one): Morning Afternoon Early Evening
NOTICE TO LANDLORD AND/OR AGENT
(Section 5321.08 ORC)
This is a copy of the tenant’s application and is being mailed to you in accordance with Section 5321.08, ORC
PLEASE NOTE: The court retains one (1) percent of each month’s rent that is deposited.
TO: Lori M. Tyack, Clerk
Franklin County Municipal Court
By:
Deputy Clerk
Date:
Rev. 8/16/2022
