I/We, the undersigned, hereby provide to the best of my knowledge information required for under and by virtue of the Ordinances of the Village of Riverside for Residential Rental Registration.

Registration is due annually. Each rental property consisting of 3 or more units must complete a separate registration.

When registration is submitted, forms will be verified for completeness. A registration invoice will then be sent to the person identified as the Owner Agent.

I am applying for...

A New Rental Certificate (begins Jan. 2022)

A Certificate Renewal

Property and Owner Information

Address*

Tax Index #:

Zoning (if known):

Full Legal Name of Each Property Owner(s): *

Mailing Address of Owner 1: *

Home/Mobile Phone:*

Work Phone:*

Email Address:*

Full Legal Name of any Secondary Property Owner: *

Mailing Address of Owner 2:

Home/Mobile Phone:

Work Phone:

Email Address:

Please provide name and address information for any other owners of this property:*

Owner Agent or Representative Information

Owner Agent Name and Title:*

Mailing Address:*

Phone Contact #1:*

Phone Contact #2:*

Emergency Contact Phone # (Available 24 hours):*

Email Address:*

Service Address to send all important communications, notices of compliance or violation and citations:*

Name of the person the Village should contact to schedule inspections:*

Dwelling Unit Information

Please list each rental dwelling unit at this property address by name (Apt. A, Unit C, Apt 322, etc.) and include the approximate square footage of each unit:
*

All rental dwellings listed will be inspected in a period of three years
I/We hereby certify that all of the information contained in this registration form is true and correct, that I/we am/are authorized to sign this document of behalf of this property owner; further that any false penalties provided for by law. I/We further state that we understand all of the ordinances of the Village of Riverside or the laws of the State of Illinois or of the United States of America.

NOTE: This is a registration form for rental dwellings and it is understood that fees will be paid and inspections will be scheduled and passed before a rental certificate of compliance is issued by the Village of Riverside, Illinois.

Applicant Signature (type full name): *