Rental Registry Checklist Form Code of Maryland, Article 24, Section 19-101 et seq. You must complete a separate checklist for each affected rental dwelling unit An affected property is a residential rental property built before 1978.Owner Name* First Last Owner Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rental Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Dwelling Units at Address*Is Property Registered with Department of Environment* Property is RegisteredIs the property registration renewal current for this year?* Registration is CurrentHas the property been inspected by an accredited lead inspector for the current tenancy?* Property has been inspected for this tenancyIf the property has been inspected, provide the Lead Inspection Certificate Number for the current tenancy as required under §6-815(c) of the Environment ArticleCertificate Number*Owner Tracking #*Certificate Date* Multiple unit owners may provide unit and certification information via Excel spreadsheet, however, one Rental Registry Checklist must be signed and provided along with the attachment.***Note: After 2/24/2006, all affected properties must have a Lead Inspection Certificate for each tenancy.I SOLEMNLY DECLARE AND AFFIRM under the penalties of perjury that the information above is true, accurate and complete.Electronic Signature*please type your name above acting as your digital signature