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{[PNAME]}
1-5 Units: $50
6-10 Units: $100
11-25 Units: $175
26 & Above: $250
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{[CITY]}, {[STATE]} {[ZIP]}
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Property
Contacts
Certification
Single Family Home
Detached Unit
Apartment
Duplex
Condo
Two Family
Mobile Home
Twin
Other
No
Yes
Public
Private
No
Yes
No
Yes
No
Yes
Public
Private
Electric
Gas
Fuel Oil
Type
*
Move in Date
Is Dwelling Vacant?
*
Heating Dealer Address
Oil
*
Heating Dealer Name
Block
Specify which of the following utilities are provided at this property by the Property Owner.
Water
*
Building Name(s)
Heating Details
Heating Dealer Phone #
Zone
Lock Box #
Utilities
Electric
*
Lot
Property Type
*
# of Bedrooms
Lockbox Location
Total # of Buildings on Property
*
If Other
Sewer
*
Gas
*
Property Details
# of Dwelling Units
*
Address
*
Heating Grade
Corporation
Individual
Partnership
Other
No
Yes
Owner
Realtor
Other
Resident Receiver Name
Address
City, State, ZIP
Address
Email
*
Email
Name
Property Owner
Name
Type
*
Mailing Address
Realtor Details
Phone #
Disclaimer: If a Tenant is a minor, you must specify their age.
Tenant Details
Maintenance Provider
Phone #
*
Business Name
Company Name
Name
*
Phone #
Is the property owner outside of the county?
*
If Yes, provide the Resident Receiver's information below.
Phone #
*
City, State, ZIP
Full Address, City, State, ZIP
Address
Mortgage Company
Who is the emergency contact person?
*
City, State, ZIP
Name
City, State, ZIP
Emergency Contact
Email
Submit
Yes
No
Type Full Name :
Sign With Hand
Clear
Done
Is your rental property served by well water?
Attachments
Certification
N.J.A.C. 5:29-1.1
5:29-1.1 Applicability
(a) Pursuant to N.J.S.A. 46:8-28 and 46:8-29, the form prescribed by this subchapter is required to be given by landlords to tenants in single unit dwellings and in two – unit dwellings that are not owner-occupied and to be filed in the office of the clerk of the municipality in which any such single unit dwelling or two-unit dwelling is situated.
(b) Tenants in multiple dwellings are required to be given a copy of the certificate of registration filed with the Bureau of Housing Inspection in accordance with N.J.S.A. 55:13A-12, N.J.S.A. 46:8-28 and N.J.A.C. 5:10-1.11. (Contact the Bureau of Housing Inspection, P.O. Box 810, Trenton, New Jersey 08625 (609) 633-6240 for registration applications for buildings with three or more dwelling units).
If yes please upload a copy of your latest well water test results.
Applicant Signature
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Female
Male
Age
Tenant Details
Unit
Last Name
First Name
Gender
Building
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