RESIDENTIAL RENTAL PROPERTY DISCLOSURE FORM (ORC 5323.02 and 5323.99) Owner Name: Contact Number: Address: City: State: City: State: Zip: Non-Resident Owner Disclosure of Agent: Agent Name: Contact Number: Owner/Applicant Signature: Date: Email: Rental Property Owned in Cuyahoga County: Rev: Oct 2017 CUYAHOGA COUNTY FISCAL OFFICER 2079 E. 9TH Street, 4th Floor Cleveland, Ohio 44115 TELEPHONE (216) 443-7020 FAX (216) 698-2748 Additional Rental Properties Owned in Cuyahoga County: (For use with exact same owner and agent information as on front, page one.) 1 Address: City: Zip: Parcel Number: Number of Units: Year Built: 2 Address: City: Zip: Parcel Number: Number of Units: Year Built: 3 Address: City: Zip: Parcel Number: Number of Units: Year Built: 4 Address: City: Zip: Parcel Number: Number of Units: Year Built: 5 Address: City: Zip: Parcel Number: Number of Units: Year Built: 6 Address: City: Zip: Parcel Number: Number of Units: Year Built: 7 Address: City: Zip: Parcel Number: Number of Units: Year Built: 8 Address: City: Zip: Parcel Number: Number of Units: Year Built: 9 Address: City: Zip: Parcel Number: Number of Units: Year Built: 10 Address: City: Zip: Parcel Number: Number of Units: Year Built: Page 2