Landlord Report Form

SUBMISSION REQUIRED UNDER MILLERSBURG BOROUGH ORDINANCE NO. 2-05

Millersburg Borough Ordinance No. 2-05 requires that all landlord/property owners who lease/rent any property within the Borough of Millersburg provide to the Borough the address of such rental or leased property and the names and other information as required on this form of the tenants of such rented or leased units. All reports required under Ordinance No. 2-05 shall be made within ten (10) days of a change of occupancy, including a vacancy.Print N/A if section(s) 3, 4, or 5 is/are not applicable.

The information requested must be provided in full or the form will not be accepted. Any individual living at this address not listed on this form constitutes a violation of Ordinance No. 2-05 and the landlord/owner may be prosecuted.

This information will be shared with the Millersburg School District Business Office and the Millersburg Borough Police Department.

Earlier versions of this form will not be accepted.

Millersburg Borough
Landlord Report Form
Revised 4.19.2018

A SEPARATE FORM MUST BE SUBMITTED FOR EACH RENTAL OR LEASED UNIT.
* represents a required field. Indicate N/A if not applicable.

 

LANDLORD / OWNER INFORMATION

Property Owner(s) Name *

Street Address *

City * State * Zip *

AC / Phone No. *

Email Address *

 

ADDRESS OF RENTAL / LEASED UNIT

House Number and Street * Apartment Number

 

NEW TENANT INFORMATION (List adults over the age of 18.)

Tenant 1 Last Name * Tenant 1 First Name * Tenant 1 Middle Initial *
Tenant 1 Date of Birth * Tenant 1 AC / Phone No. *

 

Tenant 2 Last Name Tenant 2 First Name Tenant 2 Middle Initial
Tenant 2 Date of Birth Tenant 2 AC / Phone No.

 

Tenant 3 Last Name Tenant 3 First Name Tenant 3 Middle Initial
Tenant 3 Date of Birth Tenant 3 AC / Phone No.

 

Tenant 4 Last Name Tenant 4 First Name Tenant 4 Middle Initial
Tenant 4 Date of Birth Tenant 4 AC / Phone No.

 

Tenant 5 Last Name Tenant 5 First Name Tenant 5 Middle Initial
Tenant 5 Date of Birth Tenant 5 AC / Phone No.

 

Tenant 6 Last Name Tenant 6 First Name Tenant 6 Middle Initial
Tenant 6 Date of Birth Tenant 6 AC / Phone No.

 

Tenant 7 Last Name Tenant 7 First Name Tenant 7 Middle Initial
Tenant 7 Date of Birth Tenant 7 AC / Phone No.

 

Tenant 8 Last Name Tenant 8 First Name Tenant 8 Middle Initial
Tenant 8 Date of Birth Tenant 8 AC / Phone No.

 

TENANT(S) VACATING (List adults over the age of 18.)

Tenant 1 Last Name * Tenant 1 First Name * Tenant 1 Middle Initial *
Tenant 1 Date of Birth * Tenant 1 New Address *

 

Tenant 2 Last Name Tenant 2 First Name Tenant 2 Middle Initial
Tenant 2 Date of Birth Tenant 2 New Address

 

Tenant 3 Last Name Tenant 3 First Name Tenant 3 Middle Initial
Tenant 3 Date of Birth Tenant 3 New Address

 

Tenant 4 Last Name Tenant 4 First Name Tenant 4 Middle Initial
Tenant 4 Date of Birth Tenant 4 New Address

 

Tenant 5 Last Name Tenant 5 First Name Tenant 5 Middle Initial
Tenant 5 Date of Birth Tenant 5 New Address

 

Tenant 6 Last Name Tenant 6 First Name Tenant 6 Middle Initial
Tenant 6 Date of Birth Tenant 6 New Address

 

Tenant 7 Last Name Tenant 7 First Name Tenant 7 Middle Initial
Tenant 7 Date of Birth Tenant 7 New Address

 

Tenant 8 Last Name Tenant 8 First Name Tenant 8 Middle Initial
Tenant 8 Date of Birth Tenant 8 New Address

 

NUMBER OF CHILDREN UNDER 18 LIVING AT THIS ADDRESS (Indicate even if zero.)

Number of Children *

The information requested above must be provided in full or the form will not be accepted. Any individual living at this address not listed on this form constitutes a violation of Ordinance No. 2-05 and the landlord/owner may be prosecuted.

I attest that the above information is true and correct to the best of my knowledge. *