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2. PROPERTY INFORMATION
4. Citrus Heights Property Address*
5. City, ST

   Citrus Heights, CA

6. Zipcode
   -- Select One --9561095621
8. Parcel Number*

   Need Help Finding Your Parcel Number?

10. OWNER INFORMATION
12. First Name*
13. Last Name*
15. Address*
17. City*
18. State*
19. Zip*
21. Email Address
22. Daytime Phone #*
23. Alternate Phone #
25. DECLARATION
    I hereby declare the following:
    I am the property owner for the property described above.
    
    I understand and acknowledge that pursuant to Division 3, Subdivision V of Chapter 50 of the Citrus Heights Municipal Code all rental housing properties and rental housing units are subject to routine periodic inspection by the City of Citrus Heights.
    
    I believe that the property noted above is/are exempt from inspection for the following reason(s):
27. Reason for Exemption*

    Supporting documentation is required
    

    1. The unit(s) is not a rental housing unit as defined by the Citrus Heights Municipal Code Section 50-244
    2. The unit(s) is subject to routine interior and exterior periodic inspection by another government agency
    3. The unit(s) is/are newly constructed and has/have passed final inspection by the City of Citrus Heights within the last five (5) years
    4. I/We no longer own this property
29. It is unlawful for any person to knowingly make a false statement of fact or knowingly omit any information that is required to register a rental housing unit (CHMC 50-247)
31. Agency Name
32. Affordable Housing Participation

    Required: An inspection report, agency agreement, or proof of payment. Documentation must be current and must show the rental property address. 

33. Proof of Sale
35. Not a Rental Because

    1. I own and occupy the unit
    2. I own and occupy one unit in a multiple unit dwelling
    3. The unit(s) is/are occupied by a family member within one generation of the legal owner of the property
    4. Other
36. Owner Occupied Address / Explanation of Other

    Address of the unit you occupy within a multiple unit dwelling / Explanation of why this is not a rental unit under CHMC 50-244.

38. Family Member First Name
39. Family Member Last Name
40. Family Member Phone
42. Relationship to Owner
43. Documentation of occupancy

    We require supporting documentation to show occupancy and will accept ONE of the following:

    1. Proof of Cable, Internet or Phone service at the location...or
    2. Property Taxes at the location...or
    3. Voter Registration at the location

    We do not accept utility bills as supporting documentation.

45. Documentation of family member

    We require supporting documentation to show the family connection and will accept the following:

    1. If last name is the SAME as the owner of the property - a Driver's License will be accepted.
    2. If last name is DIFFERENT from the owner of the property - a Birth Certificate will be accepted.
49. I understand that if I engage in the business of rental housing with any non-exempt rental housing unit(s), I am required to register the property with the City of Citrus Heights Rental Housing Inspection Program and must pay any and all related fees as required by Municipal Code regardless of this request for exemption. I also understand that this request for exemption may require additional documentation confirming the basis for this exemption request.
51. ELECTRONIC SIGNATURE AGREEMENT*

    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. Electronic Signature
53. Electronic Signature*
54. Date*
    Date
55. Supplemental Submittals

    Optional:  upload any additional documentation that you believe may support your request

Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

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