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 State ZIP Code
Rental Address*
Street Address Address Line 2 City State ZIP Code
Number of Dwelling Units at Address*
Is Property Registered with Department of Environment*
- Property is Registered
Is the property registration renewal current for this year?*
- Registration is Current
Has the property been inspected by an accredited lead inspector for the current tenancy?*
- Property has been inspected for this tenancy
If the property has been inspected, provide the Lead Inspection Certificate Number for the current tenancy as required under §6-815(c) of the Environment Article
Certificate Number*
Owner Tracking #*
Certificate Date*
MM slash DD slash YYYY
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
Comments
This field is for validation purposes and should be left unchanged.