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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rental Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 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 signatureCommentsThis field is for validation purposes and should be left unchanged.