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City: Page: Agent Bus. Name: No Bus. Name Street Add -No PO Box Mail Address: Street Address: Bus. Name: Title: No Bus. Name REGISTRANT ACKNOWLEDGES THAT ANY CHANGE TO THE ABOVE INFORMATION REGARDING THE PROPERTY, AGENT, OR OWNER MUST BE SUBMITTED WITHIN 30 DAYS OF THE CHANGE. REGISTRANT HAS OBTAINED AND READ THE LOCAL GOVERNMENT'S INSTRUCTIONS PERTINENT TO THIS FORM. DATE THIS FORM SUBMITTED: PRINT NAME: SIGNATURE: PHONE This form to be filed with local government by mail, email, or delivery per instructions. TAX PARCEL CITY First Name Middle Name Conveyance Document: Deed Book: IF THIS FORM IS SUBMITTED TO UPDATE A PRIOR REGISTRATION, THE COUNTY AND TAX ID# MUST BE ENTERED ABOVE , AND THE NEW INFORMATION INPUT BELOW--- AND ENTER " YES" HERE : Zip Code: Street Address: (Name entered here on electronic form acts as digital signature.) STATE/PROVINCE COUNTRY ZIP CODE STATE/PROVINCE COUNTRY ZIP CODE Phone 1 Phone 2 Fax Email OWNER MAILING ADDRESS OWNER STREET ADDRESS (no PO Box) Street Unit# First Name Email Zip City R E G I S T R A T I O N F O R M COUNTY: DCA FVPR-1 6-2012 FORECLOSED OR VACANT PROPERTY Review Local Government Instructions Before Completing CITY THIS PROPERTY IS CURRENTLY VACANT Middle Name Last Name PROPERTY INFORMATION AGENT INFORMATION (Agent for Property Owner) PROPERTY OWNER INFORMATION (Owner, Lender, Mortgagee, or Creditor) ACKNOWLEDGEMENTS Suffix IF THIS PROPERTY HAS NOW BEEN RE-CONVEYED, Enter DATE : This Space For Government Use Only. Suffix Phone 1 Phone 2 Fax Last Name