4. OCCUPANT NAMES (All Tenants Names & D.O.B):
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
Name: Date of Birth: Phone #:
5. EMERGENCY DECISIONS : Property Agent, Representative of the Owner or agent to be reached or contacted at
any time in the event of an emergency and who has the authority to make emergency decisions.
Name:
Address:
City, State, Zip:
Phone # (Day): Phone # (Cell):
There is no superintendent for this property:
6. MAINTENANCE (If Any): Name and Address of superintendent, janitor, custodian, or other individual employed
by the owner or agent to provide regular maintenance.
Name:
Address (No P.O Box):
City, State, Zip:
Phone # (Day): Phone # (Cell):
7. RECORDED MORTGAGE: Is there a recorded mortgage on this property? YES: NO:
List all holders of recorded mortgages on this property.
Name: Name:
Address: Address:
City, State, Zip: City, State, Zip:
Phone #: Phone #:
8. FUEL OIL: Identify if fuel oil is used to heat this property and the landlord furnishes the heat in this property.
Name: This property is NOT heated by fuel oil
Address: This property is heated by fuel but the landlord is not
responsible for the supply of heat
Grade of oil:
9. BEDROOMS: Number of sleeping rooms in this rental property:
10. SECURITY DEPOSITS: All security deposits with interest earned are deposited at:
I certify that the above information is true to the best of my knowledge, information and belief. I am aware that if the
going information supplied is willfully false, I am subject to penalties and criminal prosecution.
Date: Signature: Print Name:
