North irwin borough

NORTH IRWIN BOROUGH

Rental Registration/s

*Date:
*Property Owner/s:
*Address:

*Phone Number:
Fax Number:
*Email Address:

Name of Tenant	Address	*Tax Map Number	Date tenant moved in/out (Mark X on in or out)	Number of occupants
		27-01-
		27-01-
		27-01-
		27-01-
		27-01-

I hereby certify that the statement contained herein is true and correct to the best of my knowledge and belief. I understand if I knowingly make any false statements herein, I am subject to such penalties as may be presented by law or ordinance.

_________________________________

Property Owner’s Signature/s

Received by:

Borough Secretary/Treasurer

Mail or Drop off at:

Town Hall

21 2^nd Street

North Irwin, Pa 15642

Fax to: 724-863-7904

*information must be provided