REGISTRATION OF RENT FORM

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TOWNSHIP OF IRVINGTON REGISTRATION OF RENT FORM

TOWNSHIP OF IRVINGTON RENTAL PROPERTY REGISTRATION (Chapter 472 of the Municipal Code) IF YOU DO NOT COLLECT RENT; IF YOU COLLECT RENT BUT OWN A SINGLE OR TWO FAMILY HOME; OR IF YOU OWN A THREE OR FOUR UNIT HOME, BUT THE PROPERTY OWNER OCCUPIES THE STRUCTURE YOU DO NOT NEED TO COMPLETE THIS FORM.

YOU MUST COMPLETE THE FORM IN ITS ENTIRETY AND SIGN THE FORM. THERE IS NO ADDITIONAL CHARGE FOR REGISTERING YOUR RENT AND YOU ARE REQUIRED TO COMPLETE THIS FORM AS A PART OF THE CERTIFICATE OF HABITABILITY PROCESS. RETURN THE FORM TO: The Office of the Business Administrator, 1 Civic Square, Room 105, Irvington, New Jersey 07111

I. Property Location*

II. Block*

Lot*

III. I, the Undersigned, submit the following information in reference to N.J.S.A. 46:8-28 regarding the above-referenced property. I certify the information to be true and accurate.

a. Provide the name, mailing address and daytime telephone number of the record owner(s) or registered agent of the premises and the name and address of the rental business if not the same person. In the case of a partnership, the names of all general partners shall be provided. Use additional sheets, if necessary.

i. Owner or Registered Agent*

Upload state ID or driver’s license for the owner and/or registered agent

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Address*

Daytime Phone*

Email*

ii. Emergency Contact Provide the name, address and phone numbers (daytime and evening) of an individual who may be contacted in the event of an emergency affecting the premises or any unit of the dwelling.

Name*

Daytime Phone*

Address

Evening Phone

iii. Provide below the name and address of every holder of a recorded mortgage on the premises:*

b. The Property Owner or Landlord (check as appropriate)*

does

does not provide heat to the building;

c. Provide the name(s) and age(s) of all tenants living in the premises. (Use an additional fields if necessary.):

d. Unit One:

Name

Age

Rent Amount

Name

Age

Rent Amount

Name

Age

Rent Amount

e. Unit Two:

Name

Age

Rent Amount

Name

Age

Rent Amount

Name

Age

Rent Amount

f. Unit Three:

Name

Age

Rent Amount

Name

Age

Rent Amount

Name

Age

Rent Amount

g. Unit Four:

Name

Age

Rent Amount

Name

Age

Rent Amount

Name

Age

Rent Amount

Additional Units (optional)

Provide the name(s) and age(s) of all tenants living in the premises.

Upload Documents

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h. As Part of the Certificate of Habitability (“COH”) Process or the Certificate of Occupancy (“CO”) Each Rental Unit Must be Inspected. The Director of Housing (or a designee) Must Execute This Document Confirming That the Subject Property has Passed Inspection Prior to the Issuance of any COH or CO.

i. Every Owner and/or Landlord Must Provide a Copy of the Registration Certificate to Each Tenant or it Must be Posted in a Conspicuous Place Within the Common Area of the Rental Unit.

SIGNATURE OF APPLICANT:

First Name

Last Name

Date/Time*

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TOWNSHIP OF IRVINGTON REGISTRATION OF RENT FORM

Upload state ID or driver’s license for the owner and/or registered agent

d. Unit One:

e. Unit Two:

f. Unit Three:

g. Unit Four:

Upload Documents

SIGNATURE OF APPLICANT:

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