Building Division
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
AFFIDAVIT FOR HOUSE RENTAL REGISTRATION EXEMPTION
STATE OF NEW YORK
ss.:
COUNTY OF SUFFOLK
I, _____________________________, residing at _______________________________
Email address_________________________________, being duly sworn, deposes and says:
That I am the present owner of the premises located at ____________________________
______________________________________________________________________________
That I have attached hereto a copy of a Deed as proof of ownership of said premises.
That the occupant of said premises is immediate family as defined in Town Code Chapter
82. He/She is my ______________________________.
I understand that if my family relation__________________ leaves the premises and I
rent the premises that I am required to comply with the Neighborhood Preservation Act pursuant
to Chapter 82 of the Code of the Town of Brookhaven, informally known as the “Rental Law”.
I attest to this document with full understanding that I am swearing under the oath to this
fact and that swearing falsely or giving a misleading or untrue statement subjects me to
prosecution under New York State Penal Law Section 210.5.
Attachment
DATED: ______________________
______________________, New York
___________________________________
Sworn to before me this _____ day
of _________________ , 2________ . Email:_________________________________
___________________________
Notary Public
TAX MAP NUMBER __ __ __ __-__ __ __.__ __-__ __.__ __-__ __ __.__ __ __
