City Of West Chicago Deed Certification Form Page 3

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CITY OF WEST CHICAGO
DEED CERTIFICATION FORM
Copy of approved inspection sheet must accompany this application unless exempt from inspection
WE HEREBY DECLARE THE FACTS CONTAINED IN THIS DECLARATION TO BE TRUE AND CORRECT:
(PLEASE PRINT ALL INFORMATION CLEARLY)
PROPERTY ADDRESS:
P.I.N. NUMBER:
________________________________________________
______________________________
NAME OF PROPERTY OWNER / SELLER
: ______________________________________________________________________________
ADDRESS OF PROPERTY OWNER / SELLER:
__________________________________________________________________________
FORWARDING ADDRESS OF SELLER: _________________________________________________________________________
SIGNATURE: __________________________________________________
DATE SIGNED: ____________________________
(Grantor/Seller)
DATE OF DEED: ______________________
TYPE OF DEED: _________________________________________________
WAS THIS A RENTAL OR LEASED PROPERTY?
YES
NO
TYPE OF PROPERTY:
CHECK IF APPLICABLE:
□
_____ Single Family
New Construction
□
_____ Multi-Family
Relocate within West Chicago City Limits
□
Commercial / Industrial
No change in occupant or tenant
_____
□
Vacant Land ($10.00 charge)
Quit Claim
_____
□
□
Rental
Leased
NEW OWNER POSSESSION DATE: _______________ BUYER: PLEASE CHECK (if applicable):
NAME OF BUYER: ________________________________________________________________________________________
BUYER BILLING ADDRESS: _______________________________________________________________________________
FOR OFFICE USE ONLY
---------------------------------------------------------------
---------------------------------------------------------
CITY RE-INSPECTION DATE: __________________________
RE-INSPECTION FEE: $__________________________
CITY INSPECTION APPROVAL DATE: ____________________ INSPECTION FEE: $_____________________________
BUILDING SQUARE FOOTAGE: __________________________
CLOSING DATE: _________________________
RECORD NUMBER: ____________________________
Date of Filing with City
Deed Certification Number
Employee Initials

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