I, __________________ (name of guest), hereby acknowledge the receipt of all of my personal property from _________________ (hotel or motel), which were held for one of two reasons:

1. Nonpayment of account at _________________ (hotel or motel); or

2. Held for storage.

Furthermore, I release ________________ (hotel or motel) from any claim for damage or loss of any kind.

Signature of guest: __________________________________

Signature of witness: _________________________________

Date: _____________________________________________