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2. Property Owners Information
4. First Name
5. Last Name
7. Address1
9. City
10. State
11. Zip
13. Email Address
15. Phone #
17. Address Seeking Exemption for
19. Residential Rental Exemption
    Check Exemption that applies to the above address and provide detailed explanation in Notes
21. Check all that apply

    1. Dwelling unit is occupied by family member(s) where no rent or other compensation is charged or exchanged.
    2. Dwelling unit is seasonally or periodically vacant due to seasonal or secondary use by the property owner or the owner’s family only.
    3. Dwelling unit is vacant and for sale or under repair/renovation
    4. Dwelling unit is vacant and pending disposition.
    5. (Exemption is valid for up to 24 months from date of acquisition or vacancy. The Community Development Director may extend this time period for an additional 12 months per request)
23. Notes:
25. Certification
    I certify that I am the fee simple owner of the property described on this form. I further certify that all of the information contained herein is true and correct to the best of my knowledge and belief.
27. First Name
28. Last Name
30. Signature
    I understand that this constitutes a legal signature and confirms that I agree to the above terms.
31. Date
33. State of _________________
35. County of _______________
37. Sworn to (or affirmed) and subscribed before me this ____ day of ___________, 20____, by: ______________________________ has produced ________________________.
39. Notary Public Signature ____________________________
41. Name of Notary (typed, printed or stamped) _______________________________
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42. Print Only

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