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STACEY O'DAY Allen County Assessor 1 E Main St Ste 415 - Edwin J Rousseau Centre - Fort Wayne IN 46802-1811 Rentals - Phone/Fax: (260) 449-3115 email: [EMAIL REDACTED] Residential Rental Questionnaire - Confidential Owner: Phone: Email: Fax: Mailing Address: Property Address: Parcel Number: Additional Information (condition, location, or any information deemed to be helpful for assessment purposes): Property Classification Financial Information No Additional Information From Owner: If yes, are detailed estimates, photos, etc. attached? Tenant Information Duplex Unit 2 $ $ $ Unit 1 $ $ Are there any structural issues with this property? Is this property also the owner's primary residence? If yes, is the tenant responsible for the real estate taxes? Is this property "Rent to Own"? $ Yes Single Family Bathroom Count (Per Unit) Bedroom Count (Per Unit) Vacancy Rate (How many months vacant between 1/1 & 12/31?) Collection Loss (Annual) for occupied units Utilities Paid by Owner as part of lease est) Rent (Per Unit) Is this property a short-term (under 30 days) rental? Is the current tenant a family member/friend? Per IC 6-1.1-35-9, any information pertaining to income and expenses is constitutionally protected and will remain confidential. Owner Signature & Date: Information may be filed online at: www.AllenCountyAssessor.org, emailed to: [EMAIL REDACTED] or please return by mail, fax, or in person to the office below: Allen County Assessor 1 East Main Street Ste 415, Edwin J. Rousseau Centre Fort Wayne, IN 46802 Phone/Fax: (260) 449-3115 email: [EMAIL REDACTED] Questions? Please call: (260) 449-3115 attention Laura Boltz Yes No Is a copy of a current lease (within the last 18 months) attached? If no lease is in place, is the most recent Federal Income Tax return schedule (Sched E, Form 8825, etc) attached?