REV 03/10
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Foreclosure Attorney Name (if available):
Mailing Address:
Phone #:
Fax #:
Cell #: Email:
Recording Information from Lis Pendens (Please provide the Official Book and Page numbers with the recording date):
Date of Initial Inspection and Scheduled Day of Future Inspections:
Registration Form Completed by:
PRINTED NAME OF AUTHORIZED AGENT TITLE
I hereby certify that the above information is complete, true and correct; and further I understand that any misstatement of
facts contained in this application may cause the registration to be revoked, any fees paid forfeited, and further classified as
null and void. I understand it is the purpose and intent of the City to establish this process to protect neighborhoods from
becoming blighted through the lack of adequate maintenance and security of abandoned properties. Regardless of the
occupancy of the property, it shall be inspected by the mortgagee or their designee monthly on a routine schedule. Records
of inspection dates, times, and findings may be requested and must be furnished to the City upon request. Any changes to
the information supplied on this application form must be filed within ten (10) days of said change. Dania Beach City Code
requires all properties to be maintained and secured in accordance with the City Code. Any violations of City Code are
subject to the minimum penalty of $250.00 for the first offense, and up to $500.00 for each subsequent offense. I also
understand that the property may be inspected from time to time to determine compliance with all applicable City Codes.
SIGNATURE OF AUTHORIZED AGENT DATE
State of:
County of:
The foregoing instrument was acknowledged before me, the undersigned Notary Public in and for the State of:
, on this, the day of , 20 , by (Print Name):
, (Print Title): , who is
personally known to me or produced the following identification (type):
.
Witness my hand
And official seal:
Signature of Notary Public, State of
Printed name of Notary Public, exactly as commissioned
OFFICE USE ONLY: DO NOT COMPLETE BELOW THIS LINE
PROPERTY ZONED:
FEE PAID: VIA
CODE APPROVAL BY:
DATE:
CONDITIONS (IF ANY):
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signature
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