Landlord Rental Registration – City of Breese, Illinois

Please complete a new registration for each location.

Please check all that apply:

Owner

Management Entity

Rental Agent

Owner/Landlord

Individual Name:

Primary Phone Number:

Secondary Phone Number:

Email:

Name of Entity or Group:

Corporation, LLC, Partnership, Group, etc.

Business entity number assigned by the Secretary of State of Illinois:

Mailing Address of Owner/Landlord/Entity/Group:

City

State/Province

Zip/Postal

Officers/Managers/Managing Partners/Registered Agents

Name (1):

Title:

Phone:

Email:

Address:

City

State/Province

Zip/Postal

Name (2):

Title:

Phone:

Email:

Address:

City

State/Province

Zip/Postal

Name (3):

Title:

Phone:

Email:

Address:

City

State/Province

Zip/Postal

Agent/Management Entity

Name of Owner's Agent/Management Co:

Agent Contact Name:

Agent Email:

Agent Address:

City

State/Province

Zip/Postal

Rental Property Information

Legal Address of Rental Premises

City

State/Province

Zip/Postal

Type of Property:

Single Family/Mobile Home

Duplexes

Multi-Family

Number of Units

Type of Lease:

Short Term (less than 30 days)

Long Term (30 days or longer)

Unit Name:

Deregister Rental Property

Reason to Deregister:

Owner Occupied

Property Sold

If sold, new owner?If sold, new owner?

Acknowledgement

I hereby certify and affirm that the above information is true and correct and that by checking this box constitutes a legal signature confirming I am the owner, officer, manager, managing partner, or registered agent of the above listed rental property. I confirm that I have reviewed and understand the City of Breese Municipal Code Article IX - Residential Rental Properties listed on the website.

Electronic Signature:

First Name

Last Name

Date

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