Rev: Oct 2017
CUYAHOGA COUNTY FISCAL OFFICER
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2079 E. 9
Street, 4
Floor
TH
th
Cleveland, Ohio 44115
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TELEPHONE (216) 443-7020
FAX (216) 698-2748
RESIDENTIAL RENTAL PROPERTY DISCLOSURE FORM
(ORC 5323.02 and 5323.99)
Owner Name: ____________________________________________________________
Contact Number: _________________________________________________________
Address: _________________________________________________________________
City: ____________________________ State: ____________ Zip _____________
(If outside Ohio, must name Ohio agent. See below.)
Ownership Type:
Individual
Corporation
Trust
Other: _____________
If owned by a business entity or trust, the corporate officer, manager, partner, or trustee must be listed.
Corporate Officer/Trustee Name: ________________________________________
Contact Number: ________________________________________________________
Address: _________________________________________________________________
City: ____________________________ State: ____________ Zip: _____________
Non-Resident Owner Disclosure of Agent:
Agent Name: _____________________________________________________________
Contact Number: ________________________________________________________
Address: _________________________________________________________________
City: ____________________________ State:
Ohio
Zip: _____________
Owner/Applicant Signature:
Date: _________
Email: _______________________________________________________
Rental Property Owned in Cuyahoga County:
Address: ______________________________ City: ___________________________ Zip: ___________
Parcel Number:
______________________ Number of Units: _____________ Year Built: ______
Additional properties can be listed on the back, page 2.