LANDLORD INFORMATION STATEMENT
(Public Law 1974, Chapter 50)
DATE:
FOR PREMISES LOCATED AT:
                                           MOORESTOWN, NEW JERSEY 08057
   1. Name and Address of Owner(s) of Record:
   2. Record owner(s) of rental business (if any):
   3. If Record Owner(s) is a corporation, name corporate officers:
       □ Record Owner is not a corporation.
   4. If the address of Record Owner is not located in the County in which the premises are located
      (Burlington County), the name and address of a person who resides in, or has an office in, the
      county in which the premises are located and is authorized to accept notices from a tenant and to
      issue receipts therefor and to accept service of process on behalf of the Record Owner:
       □ The address of record owner in the county in which dwelling is located:
   5. Name and address of managing agent of the premises, if any:
       □ There is no managing agent.
   6. Superintendent, janitor, custodian or other individual employed to provide regular maintenance
      service, if any:
       □ There is no superintendent, janitor, custodian or other individual employed to provide regular
            maintenance service.
   7. Name, address, and telephone number of an individual representative of the Record Owner or
      Managing Agent who may be reached or contacted at any time in the event of an emergency
      affecting the premises or any unit of dwelling space herein, including such emergencies as the
      failure of any essential service or system, and who has the authority to make emergency decisions
      concerning the building and any repair thereto or expenditure in connection therewith:
   8. Name and address of every holder of a recorded mortgage on the premises:
                                                                                 FOR OFFICIAL USE ONLY:
                                                                      Date Received:
Registrant Signature                                Date              Time Received:
                                                                      Received By:
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       THIS FORM WILL NOT BE ACCEPTED IF IT IS ALTERED IN ANY WAY.