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Attachment B ��,1� OFFICE USE ONLY: <br />��r Fee: $25 PER UNIT <br />COMMUNITY DEVELOPMENT DEPARTMENT • ReferenCe �$: <br />2660 CIVIC CENTER DR. • ROSEVILLE, MN 55113 Date: <br />PHONE: (651) 792-7016 • FAX: (651) 792-7070 ReCelpt #: <br />rentalhousing@ci.roseville.mn.us <br />Entered: <br />RENTAL REGISTRATION PROGRAM 2009-2010 <br />PROPERTY ADDRESS: PIN: <br />The above referenced property is: ❑ EXEMPT: Rented to a relative/step-relarive (Complete Affidavit of <br />❑ RENTED to a non-relarive and non-group home provider Exemprion) <br />Keguired to regzstev�paopeaty. Co�nplete re�nainder of foa�n. Keturn fo�rn and ❑ EXEMPT: Rented to/owned by a group-home provider <br />�$25 fee to the City of Koseville. ❑ NOT RENTED <br /># of Renters: <br />The owner is: � An Individual <br />Name of Pxopext� Ownex (Individual�: <br />Addxess: <br />City: <br />Home Phone: <br />State: <br />Cell Phone: <br /># of Bedrooms: <br />Zip Code <br /># of Bathrooms: <br />� A Compan��Coipoxation <br />Name of Pxopext� Ownex (Compan��Coipoxarion�: <br />Name of Paxtnex ox Corpoxate Officex: <br />Addxess: <br />City: State: <br />Office Phone Fax: <br />Zip Code: <br />The property � Pxopext� Ownex (if so, pxoceed to the � Designated Agent fox Pxopext� Ownex (an� pexson authorized to make <br />contact is: next Section � ox oxdex xepa�s ox seivices on behalf of the Pxopext� Ownex� <br />Name of Designated Agent fox Pxopext� Ownex : <br />Addxess: <br />Cit�: State: Zip Code: Fax: <br />Home Phone: Cell Phone: Office Phone <br />I certify that the information contained in this form is true to the best of my knowledge. I certify that I have read and that I <br />understand the conditions under which my rental registration, if not exempt, may be suspended or revoked. I hereby agree to <br />notify the City of any changes in ownership or type of occupancy. <br />Signature (of Owner, Parmer or Corporate Officer) <br />Printed Name (of Owner, Parmer or Corporate Officer) <br />D ate <br />