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2. Manager/Owner:*
3. Phone Number:*
5. Date Completed:
   Date Completed:
6. Does unit have current rental license?*

   1. Yes

   1. No
7. Rental License Number:
   Please note, "N/A" if not applicable
9. Unit Address:*
11. Size in Square Feet:*
12. Number of Bedrooms*
13. Rent Requested:*
15. Are there other rental units in the building?*

    1. Yes

    1. No
16. If yes, how many:*
    Please note, "0" if not applicable
18. Type of Unit:*
    -- Select One --Single FamilyDuplexFour Plex or Row HouseApartment HouseMobile Home
19. Date Built:*
    -- Select One --Prior to 19501951-19601961-19801981-19951996-present
21. Amenities/Facilities*

    Please check only those that are supplied or available at no extra cost.

    1. Air Conditioning
    2. Carpet
    3. Coin-operated Laundry
    4. Dishwasher
    5. Drapes/Miniblinds
    6. Dryer

    1. Extra Insulation
    2. Garbage Disposal
    3. Handicapped accessible
    4. Laundry hookups
    5. None

    1. Microwave
    2. Off-street Parking
    3. Site Management/Maintenance
    4. Washing Machine
    5. Yard
23. Utility Information
25. Is the heat in this unit:*

    1. Gas
    2. Oil
    3. Electric
    4. Bottle Gas
26. Is the oven/stove in this unit:*

    1. Gas
    2. Oil
    3. Electric
    4. Bottle Gas
27. Is the water heater in this unit:*

    1. Gas
    2. Oil
    3. Electric
    4. Bottle Gas
29. Who pays the electricty bill?*

    1. Tenant
    2. Owner
30. Who pays the water/sewer/trash bill?*

    1. Tenant
    2. Owner
31. Who pays the gas bill?*

    1. Tenant
    2. Owner
    3. This unit does not have gas
33. Who supplies the refrigerator?*

    1. Tenant
    2. Owner
34. Who supplies the stove?*

    1. Tenant
    2. Owner
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field