TO ___________________________， TENANT IN POSSESSION：

　　You are hereby required to pay the rent on the premises herein described， of which you now hold possession， pursuant to a written lease， amounting to $          ， being the rent now due to me by you for the period from        ， to       ，or you are hereby required to deliver up possession of the premises， within THREE DAYS after service on you of this notice， to the undersigned or the undersigned will institute legal proceedings against you， to declare a forfeiture of the lease under which you occupy said premises and to recover possession thereof， with treble rents and damages.

　　The undersigned does （not） elect to terminate the lease if the rent is not paid within three day.

　　The premises referred to are commonly known as：

　　[address， apartment number]
　　[city， state， zip code]

　　（Legal description may be inserted）

　　DATED：  _______________

　　 _____________________（LESSOR）