2. Type of Registration*

   1. Initial Registration
   2. Annual Renewal
3. 24-Hour Emergency Contact Number*

   ex: (612) 555-1234

4. Rental License #

   ex: 001234

5. # Units in building
7. Legal Address of Rental Premises*
8. Total Occupancy*
9. Total # of bedrooms per unit
   -- Select One --1234
11. #of bedrooms on main floor*
    -- Select One --012345+

    Ground floor

12. #of bedrooms on top level*
    -- Select One --012345+

    Above ground floor (upstairs)

13. #of bedrooms in basement*
    -- Select One --012345+

    Below ground floor

15. Rental Registration and Inspection Fees
    Anyone who maintains or operates a residential rental property in the City limits of Edwardsville must first register their property with the Finance Department by January 1st of each year. This requirement applies to all residential rental categories, including single-family homes, duplexes and apartment complexes. The annual fee is based on the total number of residential rental units on a property: Annual Fee: Single Family / Mobile Home Per Unit - $40.00; Duplexes Per Building - $60.00; Multi-Family (3+ Units) Per Unit - $25.00; Late Registration Fee Per Unit - $75.00 (received after January 31st of calendar year); Initial Inspection - Free; 1st Re-Inspection - Free; Subsequent Re-Inspection (s) - $75.00.
17. Owner Name*
18. Owner Mailing Address*
20. Owner City*
21. State*
22. Zip Code*
24. Owner Home Phone
25. Owner Cell Phone
26. Owner Email Address
28. Tenant Number 1 Name
29. Tenant Number 1 Phone
30. Tenant Number 1 Email
32. Tenant Number 2 Name
33. Tenant Number 2 Phone
34. Tenant Number 2 Email
36. (If more than two (2) tenants, please provide separate attachment of tenant names, phone numbers and e-mails.)
37. Tenant Form Upload
38. Tenant Form
    Tenant Form.xls
40. Name of Owner's Agent / Management Co.
41. Agent's E-Mail Address
43. Agent Contact Name
44. Agent Address
46. Agent City
47. Agent State
48. Agent Zip Code
49. Agent's Phone Number
51. Mortgage Holder
52. Mortgage Holder's Address
54. Mortgage Holder's City
55. Mortgage Holder's State
56. Mortgage Holder's Zip Code
58. Mortgage Holder's Phone Number
59. Mortgage Holder's Email
61. Name of Buyer (if Contract for Deed)
62. Buyer's Mailing Address
64. Buyer's City
65. State
66. Zip Code
68. Buyer's Phone Number
69. Buyer's Email Address
71. Terms of Rental Registration Program*

    By signing this form the Owner and Local Agent (if applicable) agree to comply with the following terms. Failure to adhere to these terms and others outlined in the adopting Ordinance may result in violation of the Rental Registration and Inspection Ordinance. 

    • No owner shall be allowed to register any property if the owner has outstanding fees/fines due to the city.
    • Any changes occurring in ownership of a rental unit shall require a deregistration to adjust our records.
    • Rental properties shall be registered within 30 days of taking ownership. 
    • No rental unit can be rented or leased or offered for rent or lease in a manner which would result in violation of the occupancy limit permitted by the City of Edwardsville Zoning Ordinance.
    • Interior and exterior of each rental property shall be periodically inspected by the city under provisions established by the adopting Ordinance. Inspections shall be requested prior to occupancy.
    • The owner acknowledges responsibility to provide and install properly working smoke detectors in each sleeping room, within 15 foot of each sleeping room, and on each level of the unit. Carbon monoxide detectors shall be located within 15 foot of each sleeping room and on each level of the unit. 
    • ***Multifamily buildings that have a sprinkler system - annual inspection reports must be submitted.
    • I have reviewed the Inspection Checklist on the City’s website at www.cityofedwardsville.com/rental and will ensure my unit(s) meet the requirements.  
    • City Utility Bills: Section 118-98(a) of the City’s Codified Ordinances states that the occupant shall be primarily responsible for payment for utility service (water, sewer, and trash) at such premises; however, the owner of the premises shall be responsible for payment for the service if the occupant fails to pay. 

    1. I acknowledge this statement. (Late Registration or Non-compliance Fees may apply if not checked).
73. Single Family / Mobile Home
    Single Family / Mobile Home
74. Price Per Unit
75. Quantity
    Number of Single Family / Mobile Home Units
77. Duplexes
    Duplexes
78. Price Per Unit
79. Number of Unit
    Unit = 1/2 Duplex
81. Multi-Family
    Multi-Family
82. Price Per Unit
83. Number of Multi-Family Units

    Multi-Family (3+ Units) Per Unit

85. ***Multifamily: Does the building have a sprinkler system?
    -- Select One --YesNo

    if yes, upload inspection report now or email to rentalregistration@cityofedwardsville.com 

86. Sprinkler Report
88. Late Registration
    Late Registration
89. $75.00 Per Unit.
90. Quantity
    Late Registration
92. Owner's Signature (Electronic signature required)*
93. Owner's Agent Signature (Electronic Signature)
95. Shipping Cost
96. Shipping Cost
97. Taxable
98. Taxable
100. Taxable
101. Taxable
102. Shipping Cost
103. Shipping Cost
Leave This Blank:


104. Calculate Totals Proceed to Checkout

* indicates a required field