Begin typing address and select from the populated dropdown *
1-5 Units: $50
6-10 Units: $100
11-25 Units: $175
26 & Above: $250
{[CITY]}, {[STATE]} {[ZIP]}
  • Property
  • Contacts
  • Certification
Type *
Move in Date
Is Dwelling Vacant? *
Heating Dealer Address
Oil *
Heating Dealer Name
Specify which of the following utilities are provided at this property by the Property Owner.
Water *
Building Name(s)
Heating Details
Heating Dealer Phone #
Lock Box #
Electric *
Property Type *
# of Bedrooms
Lockbox Location
Total # of Buildings on Property *
If Other
Sewer *
Gas *
Property Details
# of Dwelling Units *
Address *
Heating Grade
Resident Receiver Name
City, State, ZIP
Email *
Property Owner
Type *
Mailing Address
Realtor Details
Phone #
Disclaimer: If a Tenant is a minor, you must specify their age.
Tenant Details
Maintenance Provider
Phone # *
Business Name
Company Name
Name *
Phone #
Is the property owner outside of the county? * If Yes, provide the Resident Receiver's information below.
Phone # *
City, State, ZIP
Full Address, City, State, ZIP
Mortgage Company
Who is the emergency contact person? *
City, State, ZIP
City, State, ZIP
Emergency Contact
Type Full Name :
Sign With Hand
Is your rental property served by well water?
N.J.A.C. 5:29-1.1
5:29-1.1 Applicability
(a) Pursuant to N.J.S.A. 46:8-28 and 46:8-29, the form prescribed by this subchapter is required to be given by landlords to tenants in single unit dwellings and in two – unit dwellings that are not owner-occupied and to be filed in the office of the clerk of the municipality in which any such single unit dwelling or two-unit dwelling is situated.
(b) Tenants in multiple dwellings are required to be given a copy of the certificate of registration filed with the Bureau of Housing Inspection in accordance with N.J.S.A. 55:13A-12, N.J.S.A. 46:8-28 and N.J.A.C. 5:10-1.11. (Contact the Bureau of Housing Inspection, P.O. Box 810, Trenton, New Jersey 08625 (609) 633-6240 for registration applications for buildings with three or more dwelling units).
If yes please upload a copy of your latest well water test results.
Applicant Signature *