Real Estate LPRs Form

REAL ESTATE LPRS FORM

This Real Estate LPRs Form (Landlord/Property Registration and Certification) is submitted by the registrant to identify the subject property, certify compliance with applicable local housing and safety provisions, and to disclose known conditions that affect habitability and regulatory status. All statements made herein are subject to the penalties for false statements and applicable administrative enforcement provisions.

Property Identification

Owner / Registrant Information

Financial / Administrative

Registration Fee Amount:    Fee Due Date:

Late Fee Policy:

Property Condition Disclosures

Is the structure known to contain lead-based paint or hazards (structures built before 1978)? Yes No

Known mold, mildew, or water intrusion affecting habitability? Yes No

Structural damage, collapse, or fire damage not fully repaired? Yes No

Active pest or infestation complaints within past 24 months? Yes No

Property located within a designated flood hazard area? Yes No

Inspections and Compliance

Has the property been inspected by a municipal or certified inspector within the past 12 months? Yes No

If yes, Inspection Date:    Inspector or Agency:

Required Repairs or Compliance Items Outstanding? Yes No

Certifications, Authorizations and Legal Acknowledgements

By signing below the registrant certifies, under penalty of law, that the information provided in this form is true, complete and accurate to the best of the registrant’s knowledge. Registrant acknowledges that knowingly making a false statement in this form may subject the registrant to civil fines, administrative sanctions and criminal penalties where applicable.

Registrant further authorizes authorized municipal officials and their agents to enter the property for the purpose of inspection upon reasonable notice or as otherwise permitted by law. Registrant agrees to comply with applicable housing, building, electrical, plumbing and fire safety codes and to complete required corrective actions within the timeframes ordered.

Indemnification: Registrant shall indemnify and hold harmless the enforcing authority from claims arising from the registrant’s failure to disclose known defects or to obtain required permits or approvals, except to the extent caused by the agency's gross negligence.

Governing Law; Severability: This registration and any enforcement actions shall be governed by applicable local ordinances and laws. If any provision of this form is held invalid, the remaining provisions remain in full force and effect.

Acknowledgement of Receipt (For office use)

Received by:    Date Received:

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