SECURITY DEPOSIT ITEMIZATION & SETTLEMENT STATEMENT

(Nebraska Residential Tenancies)

[// GUIDANCE: This template is designed for use by Nebraska residential landlords (or their counsel) to comply with Neb. Rev. Stat. § 76-1416. Complete all bracketed placeholders, attach supporting documentation, and serve on the tenant within 14 calendar days after termination of the tenancy and delivery of possession. Remove all guidance notes prior to issuance.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block
11. Exhibit A – Itemization of Deductions & Supporting Receipts

1. DOCUMENT HEADER

1.1 Title. Security Deposit Itemization & Settlement Statement (the “Statement”).

1.2 Parties.
a. Landlord: [LANDLORD LEGAL NAME], a [STATE] [ENTITY TYPE] (“Landlord”).
b. Tenant: [TENANT LEGAL NAME] (“Tenant”).

1.3 Premises. [FULL PROPERTY ADDRESS, INCLUDING UNIT NO.] (the “Premises”).

1.4 Lease. Residential Lease Agreement dated [LEASE DATE] (the “Lease”).

1.5 Termination Date. [TERMINATION DATE] (the “Termination Date”).

1.6 Effective Date. The earlier of (i) the date set forth below Landlord’s signature or (ii) the date of Landlord’s mailing or delivery of this Statement.

1.7 Governing Law & Forum. This Statement and any dispute arising hereunder shall be governed by the Nebraska Uniform Residential Landlord and Tenant Act (“URLTA”) and other applicable Nebraska law. Venue shall lie exclusively in the [COUNTY NAME] County Housing Court (or other Nebraska state court of competent jurisdiction). Arbitration is expressly excluded.

2. DEFINITIONS

As used in this Statement, the following terms have the meanings indicated below. Capitalized terms not defined herein have the meanings ascribed to them in the Lease.

a. “Deposit” means the security deposit (and any pet deposit) delivered by Tenant to Landlord under the Lease, subject to the statutory limitations of Neb. Rev. Stat. § 76-1416(1).
b. “Normal Wear and Tear” means deterioration that occurs without negligence, carelessness, accident, or abuse, consistent with § 76-1416(2).
c. “Itemized Statement” means the written accounting required by § 76-1416(2) & (3).
d. “Withheld Amount” means that portion of the Deposit retained by Landlord to cover unpaid rent, damages beyond Normal Wear and Tear, or other lawful charges.

3. OPERATIVE PROVISIONS

3.1 Deposit Received. Landlord acknowledges receipt of a total Deposit of $[AMOUNT] on [DEPOSIT RECEIPT DATE], broken down as follows:
• Security Deposit: $[ ]
• Pet Deposit (if any): $[ ]

3.2 Statutory Deadline. In accordance with Neb. Rev. Stat. § 76-1416(2)-(3), Landlord hereby tenders this Itemized Statement and any Refund (defined below) within 14 calendar days after Tenant (i) vacated and surrendered possession of the Premises and (ii) provided a forwarding address.

3.3 Itemization of Deductions. Attached hereto as Exhibit A is the Itemized Statement of all lawful deductions, including unpaid rent through the Termination Date, damages beyond Normal Wear and Tear, cleaning costs, and other permitted charges.

3.4 Refund / Balance Due.
a. Refund Owed to Tenant. If the Deposit exceeds the Withheld Amount, Landlord encloses a check or electronic payment confirmation in the amount of $[REFUND AMOUNT] (the “Refund”).
b. Balance Owed by Tenant. If the Withheld Amount exceeds the Deposit, Tenant shall remit $[BALANCE DUE] to Landlord within ten (10) business days of Tenant’s receipt of this Statement.

3.5 Delivery Method. Landlord is delivering this Statement and any Refund by [USPS Certified Mail / Personal Delivery / Other Method] to Tenant at the forwarding address of [TENANT FORWARDING ADDRESS].

4. REPRESENTATIONS & WARRANTIES

4.1 Landlord Representations. Landlord represents and warrants that:
a. All deductions listed in Exhibit A are lawful, reasonable, and supported by actual invoices, receipts, or good-faith estimates;
b. Landlord has complied in all material respects with Neb. Rev. Stat. § 76-1416; and
c. Landlord has not retained any portion of the Deposit for Normal Wear and Tear.

4.2 Tenant Representations. By acknowledging receipt (see § 10), Tenant represents that Tenant provided Landlord with an accurate forwarding address and vacated the Premises on or before the Termination Date.

5. COVENANTS & RESTRICTIONS

5.1 Tenant’s Right to Dispute. Tenant may dispute the Withheld Amount by delivering written notice to Landlord within thirty (30) days after Tenant’s receipt of this Statement, specifying each item contested and the factual basis therefor.

5.2 Documentation. Landlord shall retain supporting documentation for all deductions for at least four (4) years and make the same available for inspection within a reasonable time upon Tenant’s written request.

6. DEFAULT & REMEDIES

6.1 Tenant Default. Failure to remit any Balance Due within the period set forth in § 3.4(b) constitutes a default. Upon such default, Landlord may pursue all remedies available under the Lease, Nebraska law, and equity, including recovery of reasonable attorney’s fees as provided in Neb. Rev. Stat. § 76-1416(6).

6.2 Landlord Default. If Landlord fails to comply with § 76-1416, Tenant may recover the property and money due, together with reasonable attorney’s fees, as provided by statute.

7. RISK ALLOCATION

[// GUIDANCE: Indemnification is marked “not_applicable” in the metadata. Nebraska URLTA imposes statutory penalties; no additional limitation of liability is inserted to avoid conflict with the statute.]

7.1 Statutory Penalties. Nothing in this Statement shall be construed to waive or diminish any statutory penalties or remedies available under Neb. Rev. Stat. § 76-1416.

8. DISPUTE RESOLUTION

8.1 Governing Law. Nebraska law governs all disputes relating to this Statement.

8.2 Forum Selection. Exclusive venue lies in the state courts of the county where the Premises are located, specifically the Housing Court docket (if available).

8.3 Arbitration. Arbitration is expressly excluded.

8.4 Jury Trial. No jury-trial waiver is made; each party retains its constitutional right to trial by jury.

8.5 Injunctive Relief. The parties acknowledge that disputes under this Statement normally involve money damages only.

9. GENERAL PROVISIONS

9.1 Entire Agreement. This Statement constitutes the entire agreement of the parties regarding the subject matter hereof and supersedes any prior or contemporaneous communications.

9.2 Amendments. No amendment or waiver is effective unless in a writing signed by the party against whom enforcement is sought.

9.3 Notices. Any notice under this Statement shall be given as provided in the Lease or, if silent, by certified U.S. mail, return receipt requested, or by any courier providing proof of delivery.

9.4 Severability. If any provision is held unenforceable, the remainder shall be enforced to the fullest extent permitted by law.

9.5 Successors & Assigns. This Statement is binding upon and inures to the benefit of the parties and their respective successors and assigns.

9.6 Counterparts; Electronic Signatures. This Statement may be executed in counterparts, each of which is deemed an original. Electronic signatures and scanned PDFs shall be deemed originals for all purposes.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the undersigned have executed this Security Deposit Itemization & Settlement Statement as of the Effective Date.

[// GUIDANCE: Tenant signature is optional under Nebraska law but recommended for evidentiary purposes. Landlord should still deliver the Statement even if Tenant refuses to sign.]

11. EXHIBIT A

Itemization of Deductions & Supporting Receipts

Net Calculation
Deposit Held: $[ ]
Less: Total Deductions: ($[TOTAL])

Refund / Balance Due: $[RESULT]

[// GUIDANCE: Attach copies of all receipts, invoices, photographs, or other evidence supporting each deduction. If using estimates, indicate clearly and replace with actual amounts upon receipt.]

END OF DOCUMENT