City of Leesburg
Rental Property Owner Business Tax Receipt Registration
Phone (352) 728-9818, Fax (352)728-9734 501 W. Meadow St./ P O Box 490630/Leesburg, Fl 34749-0630 E-mail: tammy.kimball@leesburgflorida.gov
1. NAME OF PROPERTY OWNER __________________________________________________________ _____ Incorporated _____Partnership _____ Fictitious Name _____Sole Proprietor /Person/Landlord 2. PROPERTY OWNER’S ADDRESS: ________________________________________________________ CITY __________________________ ST ____ ZIP ____________ PHONE NO._______________ DRIVERS LICENSE # ____________________________ DATE OF BIRTH ________________
(DD/MM/YYYY)
SSN ________________________ or FEDERAL ID ________________________ 3. MAILING ADDRESS FOR RENEWALS ______________________________________ ZIP __________ IF APPLICABLE, IN CARE OF NAME ____________________________________________ 4. EMERGENCY CONTACT NAME ________________________________ PHONE # __________________ 5. ____ NEW PROPERTY OWNER ____ ADD NEW PROPERTIES TO EXISTING BUSINESS
6. I AM THE OWNER OF THE FOLLOWING RENTAL PROPERTIES:
(USE REVERSE SIDE IF MORE SPACE IS NEEDED) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
TOTAL # OF PROPERTIES _______ (1-15 units $27.57/ 16-50 units $44.10 I CERTIFY THE ABOVE INFORMATION IS CORRECT.
/
51 or more $77.18)
APPLICANT SIGNATURE______________________________________________________DATE_____________
NOTIFY THIS OFFICE IMMEDIATELY IF YOU CHANGE YOUR NAME, ADDRESS, SERVICES, TELEPHONE NUMBERS, OWNERSHIP, ETC.
FOR OFFICE USE ONLY
TAX CLASSIFICATION ___________________ FEE AMOUNT_____________ RECEIPT #______________ CONTROL # ________________________ TRANSFERED FROM CONTROL # _________________________ ISSUED BY: ________________________________________ DATE: ___________________