The image is a template of a security deposit itemization form. It is a document that is used to document the details of a property deposit. The form is divided into two columns, with the first column listing the date and the second column providing details about the deposit.

The first column lists the property address, rental period, and security deposit received. The second column provides information about the total deposit received, including the amount of rent, the total repair cost, and the total court/attorney fees. The third column provides details about necessary cleaning, the default rent not covered by any court judgment, and any court judge. The fourth column provides the total amount of court judgment for rent, cost, attorney fees, and total court fees. 

At the bottom of the form, there is a note that reads "Visit www.landlordleaseforms.com to purchase landlord lease forms package." The form also includes a space for the tenant's name and address.