Planning, Zoning & Historic Preservation Division | Department for Community Sustainability
City of Lake Worth | 1900 2
Avenue North | Lake Worth, FL 33461
Affidavit of Non-Rental Residential Property
I, ___________________________________ (name) hereby swear or affirm the following:
That I am the owner of certain property located at ______________________Lake Worth, Florida (hereinafter the
2. That I have owned the property since _______________.
3. That I am aware of the City of Lake Worth’s Ordinance regulating the REGISTRATION AND INSPECTION OF
RENTAL DWELLINGS AND MAINTENANCE thereof, Chapter 14, et seq.
4. That the premises located at ______________________________________________, is not currently
being used as a Rental property and will not be used as Rental Property in the immediate future.
□ I reside at the dwelling.
□ The dwelling is occupied by my relatives, who pay no rent or other consideration for the privilege of living at
the dwelling and they provide no maintenance or other services in return for the right to live at the dwelling, in
accordance with Section 14.3(f) of the Code of Ordinances of the City of Lake Worth.
□ The dwelling is vacant.
6. That I will comply with the requirements of Chapter 14 immediately upon the entry of an oral or written
lease for tenancy of the above captioned premises.
7. That failure to comply is in violation of Section 14-3 of the City Code.
I made this Affidavit for the purpose of securing temporary exemption from the provisions.
In accordance with the Code of Ordinances of the City of Lake Worth, I agree to notify any future owner of this
vacant building registration.
Property Address: ___________________________________________________________________________________
Number of Units: ____________________________________________ Type of Units: ___________________________
Should I begin to rent any part of my property, I understand that I must secure the proper certificate of use and local
Business tax receipt as required by Section 14-3 of the Code of Ordinances of the City of Lake Worth, Florida.
Name of Owner (printed): ____________________________________________________________________________
Signature of Owner: _________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________
City: _____________________________________ State: _____________________ Zip: __________________________
State of ______________________ County of ____________________
The foregoing instrument was sworn to (or affirmed) and subscribed before me this _______ day of ________________,
20_______, by ___________________________________ who is personally known to me or who has produced the
following identification _____________________________________.
Signature of Notary Print Name of Notary
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