Form Center

2. Property Owner Information
4. First Name*
5. Last Name*
6. Business Name, if applicable
8. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. E-mail Address
16. Phone Number (Primary)*
17. Phone Number (Secondary)
21. Rental Structure Information
23. Address*
24. City, State*
25. Zip*
27. Dwelling Units:*
    (i.e. apartments)
28. Rooming Units:*
    (i.e. dormitories)
29. Definition of Dwelling Unit & Rooming Unit
    Dwelling Unit: A single unit providing complete, independent living facilities for one or more persons, including permanent provisions for living, sleeping, eating, cooking and sanitation. Rooming Unit: Any room or group of rooms forming a single habitable unit occupied or intended to be occupied for sleeping or living, but not for cooking purposes. (Source: International Property Maintenance Code)
31. Reason for Withdrawing Rental License:*
32. Effective Date:
    Effective Date:
34. Does this property currently have an Open or Failed rental licensing inspection?*

    1. Yes
    2. No
    3. Unsure
35. Will the unit, or any units in the structure continue to be occupied by the current renters?*

    1. Yes
    2. No
    3. Unsure
39. New Owner Information (if known)
41. Name of new owner:
42. Business Name of new owner, if applicable:
44. Address1
45. Address2
47. City
48. State
49. Zip
51. Certification of License Withdrawal*
    By typing my name into this e-form, I acknowledge that all information provided is accurate to the best of my knowledge and I am hereby withdrawing a Rental Property License for the above-described property. I understand that the license will not be officially withdrawn until all rental licensing and inspection fees associated with the property applied in accordance with Dubuque City Code 14-1J-3 have been paid in full.
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field