List All Rental, Land Contract and Vacant Properties on Reverse Side
List the address and √ the type of all premises and residential structures with rental, land
contract and vacant units:
Total number of units: ____________
Address: ______________________________________________
Apartment #’s____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Additional properties may be listed on supplemental pages
I hereby acknowledge under penalty of law that I have completed this registration form truly and accurately to
the best of my knowledge.
____________________________________________
__________________________
Owner or Operator Signature
Date
This form may be reproduced as needed