CLAIM CHECK #: __________________

In giving this personal property for storage the signer accepts that the _____________ (hotel or motel) will not be liable for any damage to the previously mentioned property unless the damage was the direct result of a negligent act of ________________ (hotel or motel). If the damage was the result of _____________________ (hotel or motel) negligence than the liability of ___________________ (hotel or motel) will not exceed ___________ dollars ($____________).

Furthermore, a charge of __________ dollars ($____________) a day, or each fraction thereof, will be made after __________ (twenty-four hours) for each article left in the parcel room. In addition, _______________ (hotel or motel) is authorized to deliver property to any person presenting this check, without the necessity of showing identification. If the property is not reclaimed within __________ days, __________ (hotel or motel) may sell it at public or private sale and apply the proceeds against the charges then due and the cost of sale.

Signature of depositor: _______________________

Deposit received by: ________________________

Date: ______________________