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Statement of Exemption / Non-Rental Property

  1. Property is not a rental

  2. Property is a rental but is exempt from the Rental Housing Inspections Program for the following reasons

  3. NOTE: If the power is off for more than six (6) months, it is required that plumbing and electrical fixtures be inspected before the gas and electricity are turned back on.

  4. I certify and declare the information I have furnished on this form is true and complete to the best of my knowledge. I understand that if the status of my property changes from the above, I must contact the City of Moline Rental Housing Inspections office within fifteen (15) days of the change.

  5. Signature Approval*

  6. Leave This Blank:

  7. This field is not part of the form submission.