City:
Page:
Agent Bus. Name: No Bus. Name
Street Add -No PO Box
Mail Address:
Street Address:
Bus. Name: Title: No Bus. Name
REGISTRANT ACKNOWLEDGES THAT ANY CHANGE TO THE ABOVE INFORMATION REGARDING THE PROPERTY,
AGENT, OR OWNER MUST BE SUBMITTED WITHIN 30 DAYS OF THE CHANGE.
REGISTRANT HAS OBTAINED AND READ THE LOCAL GOVERNMENT'S INSTRUCTIONS PERTINENT TO THIS FORM.
DATE THIS FORM SUBMITTED: PRINT NAME:
SIGNATURE:
PHONE #:
This form to be filed with local government by mail, email, or delivery per instructions.
R E G I S T R A T I O N F O R M
COUNTY:
TAX PARCEL #:
CITY
First Name Middle Name
Conveyance Document: Deed Book:
IF THIS FORM IS SUBMITTED TO UPDATE A PRIOR REGISTRATION, THE
COUNTY AND TAX ID# MUST BE ENTERED ABOVE , AND THE NEW
INFORMATION INPUT BELOW
--- AND ENTER " YES" HERE :
Zip Code:
Street Address:
(Name entered here on electronic form acts as digital signature.)
STATE/PROVINCE COUNTRY ZIP CODE STATE/PROVINCE COUNTRY ZIP CODE
Phone 1 Phone 2 Fax Email
OWNER MAILING ADDRESS OWNER STREET ADDRESS (no PO Box)
Street Unit#
First Name
Email
ZipCity
Last Name
DCA FVPR-1 6-2012
FORECLOSED OR VACANT PROPERTY
Review Local Government Instructions Before Completing
CITY
THIS PROPERTY IS CURRENTLY VACANT (y/n):
Middle Name Last Name
PROPERTY INFORMATION
AGENT INFORMATION (Agent for Property Owner)
PROPERTY OWNER INFORMATION (Owner, Lender, Mortgagee, or Creditor)
ACKNOWLEDGEMENTS
Suffix
IF THIS PROPERTY HAS NOW BEEN RE-CONVEYED, Enter DATE :
This Space For Government Use Only.
Suffix
Phone 1 Phone 2 Fax
click to sign
signature
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