Rental Housing Inspections Office
Phone: (563) 326-8643
Proper
ty Address: __________________________________________________________
Property Owner: ___________________________________________________________
Completed forms should be returned to:
Scott County Planning & Development, 600 W. 4th Street, Davenport, IA 52804
or
Planning@scottcountyiowa.gov
1. Property is not a rental, meaning the property contains no dwelling unit, to be used for residential
purposes, that is rented or available for rent. (If checked, property is not subject to the Rental
Housing Inspections Program.)
2. Property is
a rental but is exempt from the Rental Housing Inspections Program for the
following reasons: (Select appropriate box)
Property is a duplex.
Property is a single-family dwelling.
Property is an owner-occupied unit/condo
COMMENTS:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify and declare the information I have furnished on this form is true and complete to the best of my
knowledge. I understand that if the status of my property changes from the above, I must contact the Scott
County Rental Housing Inspections office within fifteen (15) days of the change.
______________________
_______________ ____________________________________
Owner Signature Date
_______________________________
______ ____________________________________
Mailing Address Phone
Statement of Exemption/Non-Rental Property
(There is no fee for returning this form)
click to sign
signature
click to edit
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