Lease Agreement

  1. Rent
  2. Payment of Rent
  3. Appliances and Furnishings
  4. Bad Check Service Charge
  5. Added Rent
  6. Use
  7. Pets
  8. Nonassignment of Lease Agreement
  9. Legal Obligations
  10. Attorney’s Cost
  11. Security Deposit
  12. Cleaning Fee
  13. Tenant Insurance
  14. Lock Policy
  15. Condition of Premises
  16. Alterations
  17. Vehicle Policy
  18. Utilities
  19. Validity of Lease Provisions
  20. Access to Premises
  21. Waiver
  22. Force Majeure
  23. Legal Binding
  24. Terms
  25. Full Disclosure
  26. Addendum
  27. Default
  28. Security Deposit Agreement


1. ____________________________ 2. ____________________________
3. ____________________________ 4. ____________________________
5. ____________________________ 6. ____________________________

This agreement made this __________day of___________________, _________. By and between ________________________________ herein called the Landlord, with C.S.P. Management as it’s

Manager, and the above named, herein called the Tenant. Landlord hereby agrees to lease the real property located in the City of Ithaca, County of Tompkins, and the State of New York located at ___________________________________________.  This lease commences at 12:00 noon on the _________day of_________________, _________, for a period of: _______ months ________ days, until 12:00 noon on the ___________ day of ______________________, __________ at which time this agreement is terminated.  Landlord leases the demised premises to Tenant on the following terms and conditions:

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Tenant agrees to pay Landlord $_________________, payable in equal installments of $_____________, per month, due and payable monthly in advance on the First day of each month during the term of this lease agreement.  If the rent is not received by the fifth day of the month tenant shall pay a late fee of $50 or five-percent (5%) of the total monthly rent whichever is greater.  Upon signing lease Tenant shall pay a security deposit, in the amount of $_______________. First months rent in the amount of $_______________ is due at move in.  If Tenant defaults, Landlord may give notice to Tenant that Tenant may no longer pay rent in installments.  The entire rent for the remaining part of the lease term will then be due and payable.

Chapter 258-10(A) Waiver

As per Chapter 258-10(A) of the City of Ithaca Municipal Code, landlords shall provide a minimum of 120 days’ written notice to current tenants of a residential unit before doing any of the following:

(1) Renewing the current rental agreement

(2) Showing the residential unit to prospective new tenants or otherwise suggesting to prospective new tenants that the unit is currently available for rent

(3) Entering into a rental agreement with new tenants

By initialing here _________________________________________, I fully understand and willingly waive my rights to 120 days’ written notice in advance of the above.

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Payment of Rent

We encourage use of our online portal system for payment of rent.  Tenants may pay rent using a credit card of e-check.  There are fees associated with the use of these services.

Payment by check is also accepted.  Tenants paying with multiple checks agrees to collect and deliver payments together.  Rent payments may be paid by check until the first is dishonored and returned unpaid, then cash or money order will be required.  Time is of the essence and no excuses will be accepted.  Rent shall be made payable to:  ________________________________________ and delivered in person or mailed to:  CSP Management, 407 W. Seneca St., Ithaca, NY 14850.  Use of the mail is done so at the Tenant’s risk.  (Always indicate the TENANT’S FULL NAME, STREET ADDRESS and APARTMENT NUMBER on the check or money order.)

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Appliances and Furnishings

All appliances and furnishings currently on the property are being leased to Tenant in “as is” condition.  In signing this lease agreement, Tenant waives all claim for injury or damage to him or herself or to others arising from the use of these appliances unless due to Landlords negligence.

If Landlord pays utilities, major appliances (air conditioner, washer, dryer, dishwasher, etc.) not provided by Landlord, they may not be used without prior written permission from Landlord. There will be a $50.00 added fee for each month. Violation of this provision will result in a $75 per month fine for each month of the violation.

___If this box is checked the Landlord is providing a washer/dryer and/or dishwasher and/or microwave for use by the Tenant. All maintenance and repairs for these appliances shall be done by CSP Management and if it is deemed negligence then it will at the Tenant’s expense.

Furniture may not be moved to another apartment or used outside of apartment/house (on porches, yards, etc.).  Tenants must arrange with Landlord for removal & storage of unwanted furnishings at Tenant’s expense.

Furniture must be returned to rooms where located at start of lease term or a charge for moving same will be deducted from the security deposit.

Landlord does not provide light bulbs, lamps, window cleaning service, storm windows or screens, replacement window shades or curtain rods, other than those existing in apartment/house at start of lease.

This is a furnished/unfurnished/partially furnished apartment.

( )Bed(s)(mattress, box, frame) ( )Microwave ( )Kitchen Table
( )Desk(s) & desk chairs ( )Easy Chair ( )Kitchen Chairs
( )Dressers ( )Love seat ( )Coffee table
( )Sofa ( )End Table(s) ( )Misc. ______________

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Bad Check Servicing Charge

In the event Tenants check is dishonored and returned unpaid for any reason to Landlord, Tenant agrees to pay as additional rental the sum equal to $20.00 or five percent (5%) of the returned check whichever is greater.  If for any reason a check is returned or dishonored, ALL future rent payments will be cash or money order.

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Added Rent

Charges for late payment of rent, utilities or solid waste fee, bad check service charges, legal fees (as outlined in Section 11, Attorney’s Cost), utility reimbursements owed to Landlord, garbage and recycling fees and fines and repairs/replacements made by Landlord due to Tenant negligence or misconduct shall be deemed to be additional rent to be paid by Tenant to Landlord on the 1st day of the month following notice to Tenant of such assessments or expenditures. 

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Premises are for non-commercial, residential and exclusive use of the aforementioned tenants. Occupancy is restricted to _____________ occupants. Occupancy by any other person(s) other than the signers, without written permission is a violation of the lease.

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There shall be no pets allowed on the premises unless written permission has been granted by landlord.       If written permission has been granted, tenant agrees to sign a pet agreement with the landlord that stipulates all terms under which the animal may be allowed to be housed by tenant.

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Nonassignment of Lease Agreement

Tenant agrees not to assign this agreement, nor to sublet any part of the property (i.e. Air B&B), nor to allow any other person to live therein without written consent of Landlord.  Such consent will not be unreasonably withheld. If consent is given, the Tenant named in the lease remains responsible for the terms of this lease when subletting.  Landlord must have in writing from the Tenant – a completed application by the sublessee and a written time period for which the property will be subleased. Tenant further understand that they are still bound to and agree to fulfill the lease agreement and are responsible and liable for the actions of their sublettor.

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Legal Obligations

Tenants hereby acknowledge that they have a legal obligation to pay their rent on time each and every month regardless of any other debts or responsibilities they may have.  They agree that they will be fully liable for any back rent owed.  They also acknowledge that defaulting on this lease agreement could result in a judgment being filed against them and a lien being filed against their current and future assets and/or earnings. The parties hereby agree that the Landlord may sue the Tenant, re-enter the premises or exercise any legal remedy if the Tenant does not pay the rent or any part of it when it comes due or if the Tenant should abandon or appear to abandon the premises or if the Tenant occupies the premises for other than the approved use or if the Tenant should violate any provision, term, condition or covenant of this lease.

Both parties hereby waive trial by jury in any action brought by either of the parties of this lease against the other.  If the Landlord starts a summary proceeding for possession of the premises due to non-payment of rent, the Tenant will not interpose any counterclaim in such a proceeding.  The Tenant shall, however, have the right to bring a separate action for any claim he/she may have.

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Attorney’s Cost

Landlord may recover from Tenant on terminating the Lease for Tenant’s breach, all damages proximately resulting from the breach, including the cost of recovering the premises, back rental payments, and the worth of the balance of this Lease or the reasonable rental value of the premises for the remainder of Lease term.  If a court action is sought by either party to enforce the provisions of this lease agreement, attorney’s fees and costs may be awarded to the prevailing party in the court action.  The tenant acknowledges that the Landlord may deduct from Tenant’s security deposit a sum equal to any damages or expenses described above upon providing to the Tenant an accurate accounting of such damages or expenses actually incurred by the landlord.

Without limiting the right of the Landlord to recover damages or expenses as described above prior to the commencement of legal action, if the landlord commences any legal action in a court of appropriate jurisdiction due to Tenant’s failure to perform or abide by any lease term or condition, Landlord shall recover from Tenant the costs of such proceeding including but not limited to reasonable attorney’s fees. 

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Security Deposit

A security deposit of $__________________, previously stated in paragraph 1, is due and payable when the lease is signed.  This deposit shall be refunded within 14 days after the end of the lease term, or upon turning in keys, in accordance with the Security Deposit Agreement attached to this lease and made a part of it. 

Upon the expiration of the lease term or sooner if the Landlord re-enters the premises as the result of a tenant default or if the Landlord regains possession of the premises by any legal means, then any property left behind for more than five days will be deemed assigned to the Landlord who may dispose of the property in any manner the Landlord deems fit.  The Landlord will have no further responsibility or liability to the Tenant for any such personal property.

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Cleaning Fee

Tenant hereby agrees to accept the property in its present state of cleanliness and Landlord agrees to prepare the apartment to a broom-clean condition.  An inspection form is given to each apartment upon move in and must be returned within ten (10) days, outlining any damages, cleaning or repairs that must that are observed by the tenant.   Tenants agree to return the property in a broom clean condition or pay the costs incurred by the Landlord to have the property professionally cleaned.  Such fee will be deducted from the security deposit.

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Tenant Insurance

No rights of storage are given by this agreement. Landlord will not be liable for any loss of Tenant’s property.  Tenant hereby acknowledges this and agrees to make no such claims for any losses or damages against Landlord, his agents or employees.  Tenants agree to purchase insurance at their own expense sufficient to protect themselves and their property from fire, theft, burglary and breakage.  They acknowledge that if they fail to procure such insurance, it is their responsibility and they alone shall bear the consequences.  Renters Insurance is suggested, and may be obtained at most local insurance agencies.

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Lock Policy

Tenant may pick up keys on the first day of lease or after at the CSP Management office, 407 W Seneca Street, between 9:00am & 5:00pm, Monday through Friday.   First tenant to check in receives all apartment keys.

No additional locks will be installed on any door without the written permission of the Landlord. Landlord will be given duplicate keys for all locks so installed at the Tenant’s expense, before they are installed. A minimum of $20.00 will be deducted from the security deposit for each key issued and not returned at the end of the lease term.  If all keys are not returned, Landlord may change locks at Tenant’s expense.  Replacement keys during the term of the lease will incur a $10.00 charge per key.

If Tenant locks himself/herself out of the apartment, there is a $35.00 fee during regular business hours for Landlord or his agent to open the dwelling, payable only in cash or check and at time of opening, outside of regular business hours the fee is $50.00.   In the event the fee is not able to be paid at opening, an additional $5.00 fee will be added per day for each day the fee is not paid.   Tenant may borrow a key from the Landlord during business hours, leaving a credit card or drivers license as collateral and agree to return the key within one hour.

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Condition of Premises

Upon moving in tenants will be provided with a check-in inspection form.  This form should be completed and returned to C.S.P. Management no later than ten (10) days after taking occupancy.  Tenant(s) agree that failure to complete this form will be legally binding proof that the property is in good condition at the time of occupancy.  Tenant agrees to notify Landlord immediately if roof leaks, water spots appear or at the first sign of insect damage.

Landlord warrants that all major systems will be functional and in good repair at the time of possession.  Light switches, wall plugs, doors, windows, faucets, drains, locks, toilets, sinks, heater, etc. will either be

in working order or will be repaired after Tenant has notified Landlord.  Tenants are encouraged to report any necessary repairs, no matter how slight, in writing, but they are hereby advised that Landlord does not normally repair or replace non-functional items such as paint, carpets, etc., every time a property changes possession.

Neither the Landlord nor its agents have made any representations as to the condition of the building, the land upon which it is erected or the leased premises unless expressly set forth herein.  The tenant has inspected the premises and accepts the same “as is” and acknowledges that the leased property was in good condition at time of possession was taken.  The Landlord shall not be responsible for any latent or other defect or condition in the building, improvements and land, including but not limited to any damage caused or alleged to be caused by the presence of radon, asbestos containing material or any other similar cause whatsoever.

Good housekeeping is expected of everyone.  Tenant agrees to keep premises clean and in an orderly condition.  If this covenant is breached, Landlord may give Tenant a three-day notice to comply.  If Tenant fails to do so, Landlord may enter premises, clean it and charge Tenant for cleaning.  If the same or similar in nature violation is recurrent and Landlord deems that the apartment is not in acceptable, showable, or sanitary condition, Landlord may serve Tenant with a written notice to vacate the premises within a 30-day period.  Tenant agrees not to permit any deterioration or destruction to occur while they are occupying the premises.  They agree to maintain the walls, woodwork, floors, furnishings, fixtures, appliances, windows, doors, screens, fences, plumbing, heating, electrical and mechanical systems as well as the general structure and appearance of the property.  Grease, oil, coffee grounds, fibrous materials or tampons must not be flushed down toilets or drains.  Tenant is responsible for blockage to sewage or drainpipes, and any overflow from same.   Tenant is responsible for clearing any clogged drains after beginning of lease term.   No flushable wipes, feminine hygiene products, or paper towels may be put in toilets.   Tenant is responsible for cost to remove clog.

Tenant shall not play musical instruments, radio, T.V. or stereo loud enough to be heard by other tenants or neighbors.  Tenant may not play music outdoors.  Tenant(s) will respect the rights of other tenants and their neighbors and will be responsible for the conduct of their guests.  They agree to conduct themselves in a way that will not interfere with the quiet enjoyment of the adjacent or surrounding neighbors.  If Landlord deems Tenant’s conduct to be offensive and objectionable or if Tenant engages in any illegal activity, Landlord shall give Tenant notice of such determination and Tenant will thereafter remove himself from the premises on or before the expiration of a ten-day period.

Garbage must be put in designated area not later than 5:30 a.m. on collection day.  At no time may trash or recyclables be left in the hallway outside the apartment.   Tenants are subject to a $50 fine for violation of this clause.   Tenant agrees to abide by any laws pertaining to recycling and garbage regulations established by local municipalities or government authority.  Laws pertaining to recycling and garbage regulations may be obtained from the Property Manager.

Smoking is not allowed anywhere in the building.

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Tenants shall make no alteration, additions or improvements in or to the premises without Landlord’s prior written consent, and then only by contractors or mechanics approved by Landlord. Tenant must keep, and, at the end of the rental term, return the premises clean and in good order and repair. Tenant may not alter, paint, change or add to the premises without the consent of the Landlord. The use of adhesives to attach articles to the walls, ceilings or other painted surfaces is prohibited. Tenant may use single nails to hang artwork or mirrors on walls. If Tenant defaults as to this obligation, Landlord has the right to make repairs or to restore the premises to original condition, and to charge Tenant the cost of such repairs. All alterations, additions or improvements to the premises, made by either party, shall become the property of the Landlord and shall remain upon, and shall be surrendered with said premises, as a part thereof at the end of the lease term.  Tenant may not tamper with, alter or disconnect the power supply of any smoke or heat detection device.  A minimum charge of $50.00 will be made for each violation.  Tenant shall not cause any signs, posters, decorations, or similar articles to be placed in the hallways or outside of the building or in the windows of the leased premises.   Landlord may enter onto the leased premises to remove any such signs, posters, decorations, or similar articles and charge Tenant the reasonable cost of removal of same.

  The Tenant specifically acknowledges that they will be responsible for and pay for any damage done by rain, wind, hail, tornadoes, hurricanes, etc., if this damage is caused by leaving windows or doors open, and for torn screens, broken doors or lock, due to the negligence of the Tenant.

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Vehicle Policy

The Tenant agrees never to park or store a motor home, camper, trailer or any sort of recreational vehicle on the premises. Tenant(s) shall be authorized to park a maximum of ________car(s) in the parking area provided. Non-functional vehicles or unlicensed automobiles are not permitted on the property. Removal of such vehicles will be at Tenant’s expense. No parking is allowed on grass or between the sidewalk and the apartment building. (See parking lease attached)

Parking Space Rental ( )Yes ( )No Space#_____ Permit#_____
Garage Rental ( )Yes ( )No Garage#_____ Permit#_____

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Responsibility designated below

Utility Tenant Landlord
Cooking Gas ( ) ( )
Electric ( ) ( )
Heat ( ) ( )
Hot Water ( ) ( )
Water & Sewer ( ) ( )
Lawn Care ( ) ( )
Snow Removal
Driveway ( ) ( )
Sidewalks ( ) ( )
Trash Removal
Annual Solid Waste Fee ( ) ( )
-($4.43/month) $____________ due upon lease signing(Amt. subject to change based on County Budget for the new year.)

Your trash pick-up day is: __________________   

If Tenant pays utilities to NYSEG (indicated above) it is Tenant responsibility to arrange for service to be put in Tenant’s own name and turn on before lease begins and leave in tenant’s name for the entire term of the lease.  Keys shall not be issued to Tenant until Landlord has confirmed that all services are in Tenant name. Call NYSEG (800) 572-1111, to arrange for this service.  If, Tenant is reimbursing Landlord for any utility or garbage bill (ie: water/sewer, etc.), the procedure is as follows:

                          a) Landlord will mail Tenant a copy of each utility bill.

  b) Tenant will reimburse to Landlord the net amount as stated in lease,in one               check; multiple checks fromindividual tenants will not be accepted.

                          c) Payment is due within 10 days of receipt of bill.

  d) A penalty of $1.00 per day will be charged for any payment received after the due date.

Cable television, telephone, and internet are to be arranged for and paid by the Tenant directly with the providers of these services. 

Tenant specifically authorizes Landlord to deduct amounts of unpaid bills and late fees from their security deposits in the event that they remain unpaid after termination of this agreement.

Tenant is required to maintain adequate heat in winter to prevent pipes from freezing and to maintain a 55-degree thermostat setting to prevent damage during vacation periods.

If Landlord pays for heat, for all or any part of the building, tenant must keep all doors and windows, including exterior and interior doors and interior and storm windows, closed during the heating seasons (September 1 to April 15). 

Any violation of this energy conservation requirement will result in a $25.00 charge for each day of the violation. If landlord is unable to determine the person(s) responsible for the violation, all tenants of the building will share the amount of the violation, based upon number of rooms rented. Any problems with heating system must be reported to Landlord immediately. Unvented heaters, kerosene heaters or space heaters are prohibited in any room, apartment or building.

If Landlord pays for water and sewer for all or any part of the building the tenant must report all dripping faucets, running toilets or any other water wasting issues. If the Landlord incurs a bill for water and sewer that is higher than the usual average bill for the property from previous quarter billings, and it is determined that the tenant has neglected to report a water wasting issue the Tenant understands that they will be billed for the difference.

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Validity of lease Provisions

Any provision set forth in this lease agreement which is contrary to New York State law shall be treated by Landlord and Tenant as void and as if it were not set forth herein, however, all other provisions of the lease agreement shall remain in full force and effect.

Tenant represents that he/she/they is/are 18 years of age or over.

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Access to Premises

The Landlord reserves the right to enter the residence at reasonable times to inspect, make necessary repairs, supply services or show it to prospective residents, purchasers, mortgagees, workers or contractors.  Whenever practical, a one-day notice of the Landlord’s intent to enter the property shall be given to the tenant. Any notice sent by Landlord to tenant by e-mail at the e-mail address provided by tenant shall have the same legal effect as a notice sent to tenant by U.S. Postal Service. The Landlord may also display “For Rent” or “For Sale” signs on the premises. Tenant agrees to vacate property with 60 days written notice in the event that the property is sold. For 6-7 months prior to the end of the lease term the Landlord reserves the right to show the unit on weekdays between 10:00 AM and 5:00 PM.

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All rights given to Landlord by this agreement shall be cumulative in addition to any laws which exist or might come into being.  Exercise of any rights by Landlord or failure to exercise any rights shall not act as waiver of those or any other rights. No statement or promise by Landlord, rental agents, or employees, as to tenancy, repairs, amount of rent to be paid or other items and conditions shall be binding unless it is put in writing and made a specific part of this agreement

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Force Majeure

In the event that either party shall be delayed, hindered in, or prevented from the performance of any act required by this lease by reason of strikes, lock-outs, labor trouble, inability to procure materials, failure of power, restrictive governmental laws or regulations, riots, insurrection, war, natural disaster, or other reason of a like nature, not the fault of the party delayed in performing work or doing acts required under the terms of this lease the Landlord will not be held liable nor will rent be owed until the unit is ready for occupancy.

Legal Binding

Tenants hereby state that they have the legal right to sign for any and all other residents and to commit them to abide by this contract. All tenants agree to be jointly and individually responsible for rent, damages and all other charges and obligations, hereunder.

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In this agreement the singular number, where used, will include the plural and vice-versa; the masculine gender shall include the feminine and vice-versa; the terms Owner, Landlord and Lessor may be used

Interchangeably, and the terms Resident, Tenant and Lessee may be used interchangeably.

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Full Disclosure

The Tenants signing this lease agreement hereby state that all questions about this lease contract have been answered, that they fully understand the provisions of the agreement and the obligations and responsibilities of each party, as spelled out herein. They further state that they agree to fulfill their obligations in every respect or suffer the full legal and financial consequences of their action or lack of action in violation of this agreement.  Signature by Tenant on this lease agreement is acknowledgement that Tenant has received a signed copy of the lease contract.

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The following is an additional agreement made between Tenants and Landlord


Sprinkler System Disclosure

___There is presently NO maintained and operative sprinkler system in the leased premises.

___There is presently a maintained and operative sprinkler system in the leased premises. The system was last maintained and inspected on ____/______/______. I, the undersigned Tenant under the above-captioned residential lease understand that this clause is being presented to me pursuant to and in accordance with the requirements of New York State Real Property Law, Article 7, Section 231-a, which has become a requirement of law as of December 3, 2014. I acknowledge its receipt herein.


If Tenant moves out before expiration of the lease or before lease begins Tenant understands that until such time as the apartment is re-rented, Tenant agrees to abide by the terms of the lease, including timely monthly rental payments. Tenant may contract with the Landlord or manager to undertake the re-renting of the apartment, it is the responsibility of the Tenant to pay a minimum of one half of one months rent and any associated advertising costs, for this service, together with other charges due to the Landlord under this lease contract. If Tenant finds someone to re-rent the apartment on their own, it is agreed that this person must complete the application process and be approved by the Landlord or manager. Tenant further understands that Tenant is responsible for all court costs associated with the court proceedings for default and or damages under the terms of this lease contract.

Accepted this ________________ day of________________________________, ________


________________________________________________ ________________________________________________
Tenant Tenant
________________________________________________ ________________________________________________
Tenant Tenant
________________________________________________ ________________________________________________
Tenant Tenant
________________________________________________ ________________________________________________
Tenant Tenant  


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Security Deposit Agreement



Return of Security Deposit is subject to the FOLLOWING PROVISIONS

1. Full term of lease has expired.
2. No damage to the property, appliances & furnishings beyond reasonable wear and tear.
3. Entire apartment including range, refrigerator, bathroom, closets and cupboards are clean. All           garbage, paper and debris removed.
4. No stickers, scratches or holes on the walls, Small nail and tack holes permitted.
5. No delinquent rents or unpaid charges under the lease agreement.
6. All keys returned no later than 12 noon on the day the lease expires. (Rent will be charged for each day keys are not returned).
7. All furniture returned to the location as at the start of the lease.
8. Forwarding address left with the Landlord’s Agent, C.S.P. Management.

If any of the above conditions are not complied with, the applicable fines or cost of the labor and materials will be charged to the Tenant(s). The security deposit is returned by check and mailed to Tenants’ forwarding address. This is done within fourteen (14) days after delivery of possession of the leased premises and the keys to the Landlord at the end of the term of the lease. The check is addressed jointly to all persons who signed the lease, regardless of who deposited the money, unless all Tenants sign written directions otherwise. No pick ups from the office shall be made. Landlord agrees that, subject to conditions listed above, the security deposit will be returned in full. If there are six or more units in the building, interest will be given. However, Landlord need not give Tenant interest on the security if Tenant has not fully performed any term of the lease.

Security Deposit is being held at: ___________________________________________

DATE: _____________________________________

LANDLORD/MANAGER: _________________________________________

1. _________________________4. _________________________
2. _________________________5. _________________________
3. _________________________6. _________________________


Sublet Information

Subletting of a tenant’s apartment is allowed with written permission of the Landlord. CSP does not find Sublette’s for a tenant, especially when more than one individual lives in the apartment.

You can however give the tenant some suggestions (school bulletin boards, Ithaca Times, etc.) and be sure to give them the following information on how to sublet their apartment:

Sublet Information (Word DOC)
Sublease Agreement (Word DOC)

Mail form to:
CSP Management
407 W. Seneca Street
Ithaca, NY 14850

Acknowledgement of Payment Assistance

Parent or guardians may assist tenants with payments. Parents/Guardians will need to print, sign, and return this form. Download the form here:
Payment Assistance Form (PDF)

Mail form to:
CSP Management
407 W. Seneca Street
Ithaca, NY 14850

Or fax the signed form: 607.277.0377



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