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2. Registration and Fees
   • The fee for each subsequent semi-annual registration shall increase by $100 over the amount of the fee most recent-ly paid and is due within ten (10) days of the expiration of the previous registration.
   • If the fee for the vacant/defaulted mortgage property is not paid within 30 days of when the registration is required pursuant to the above-referenced Code section, a late fee equivalent to 10 percent (10%) of the semi-annual regis-tration fee shall be charged for every 30-day period, or portion thereof, that the property is not registered and shall be due and payable with the registration.
   • One registration form is required for each vacant/defaulted property.
4. Property Information
6. Vacant/Defaulted Mortgage Property Address*
8. Are you the owner or mortgagee?
   -- Select One --OwnerMortgagee
10. Owner's Full Legal name
12. Owner's Address
14. City
15. State
16. Zip
18. Owner's Home/Business Phone Number
19. Owner's Cell Phone Number
21. Owner's Email Address
23. If a Corporation or LLC, Name & Address of Registered Agent
25. Mortgagee's Name
27. Mortgagee's Address
29. City
30. State
31. Zip
33. Mortgagee's Phone Number
34. Mortgagee's Email Address
36. Name and Address of Company President
38. If the property has a manager other than the owner/mortgagee listed above, please provide the following information:
40. Property Manager's Full Legal Name
42. Property Manager's Address
44. City
45. State
46. Zip
48. Property Manager's Home/Business Phone Number
49. Property Manager's Cell Phone Number
51. Property Manager's Email Address
53. Important Information
    • City staff may at any time require additional relevant information of the owner, mortgagee, or property manager to clarify items on the Registration Form.
    • If the property owner, mortgagee, or property manager changes his/her address or any other information provided on the registration form, and fails to notify the appropriate City staff, as referenced below, all notices shall be suffi-cient if sent by first class or certified mail to the owner, mortgagee, or property manager’s last address listed on the Registration Form.
55. Electronic Signature Agreement

    • I understand that this Registration Form cannot be transferred to another property or owner. I also understand that if there are any changes to the property ownership or any information provided on this form that I MUST NOTIFY City staff as referenced below.
    • I understand that if I receive a notice and fail to bring the property into compliance, the sale of the property will not relieve me of the responsibility for compliance as ordered by the City. I understand that compliance may require per-mits and if so, I will obtain those permits and call for inspections as required. I UNDERSTAND THAT ALL WORK MUST CONFORM TO THE CODES OF THE CITY OF MOLINE AND THAT LICENSED CONTRACTORS UNDER PERMIT MUST COM-PLETE ELECTRICAL, PLUMBING, AND/OR HEATING/AC WORK.
    • I certify and declare the information I have furnished on this Registration Form is true and complete to the best of my knowledge. I understand that approval of this Application is conditioned upon compliance at all times with all applicable ordinances, regulations and statutes of the City of Moline and State of Illinois.
    • By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Electronic Signature
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field