BOARD OF ASSESSMENTSACT 29 — PROPERTY CONTACT INFORMATION FORM

BOARD OF ASSESSMENTSACT 29 — PROPERTY CONTACT INFORMATION FORM
Only use this form for real property that is NOT owner-occupied as the owner's principal residence.

Required: Under 68 Pa.C.S. § 2504, owner-occupant real property is exempt from Chapter 25.

Submit completed form to the address below or online

Delaware County Board of Assessments
Government Center — Ground Floor
201 West Front Street
Media, PA 19063
Phone: 610-891-4891
Property Assessment: 610-891-4887
BOAACT29@co.delaware.pa.us
PART 1 — PROPERTY INFORMATION
Delaware County Property/Parcel ID Number:
Property Address:

Street Address

City/Borough/Township

StatePostal / Zip Code

Municipality
Date Property Purchased / Acquired:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Property Occupancy - Is this property owned and occupied by an individual's principal residence and domicile?

PART 2 — OWNER TYPE
Check one:
Note: The statutory definitions of "business," "limited liability company," and "real property owner" are found in 68 Pa.C.S. § 2501.

PART 3A — INDIVIDUAL OWNER

Complete this section if the property owner is an individual, then go to Part 4.
Full Legal Name:

First NameLast Name
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Property Manintenance / Code Contact

If different from the owner
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Does this individual have the authority and ability to repair, maintain, or otherwise remedy a problem or municipal code violation concerning the property?

PART 3B — BUSINESS / ASSOCIATION OWNER

Complete this section if the property owner is a business or association other than an LLC, then go to Part 4.

Business Information
Legal Business Name:
Legal Business Name
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number:

Area CodePhone Number
Owner / Employee Contact
Name of Owner or Employee:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Property Maintenance / Code Contact
Name of Individual / Representative / Employee:

First NameLast Name
Title / Position:
Title / Position
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Does this person have the authority and ability to repair, maintain, or otherwise remedy a problem or municipal code violation concerning the property?

PART 3C — LIMITED LIABILITY COMPANY (LLC)

Complete this section if the property owner is an LLC, then go to Part 4.

LLC Information
Legal LLC Name:
Legal LLC Name
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone Number:

Area CodePhone Number
Name of Member or Manager:

First NameLast Name
Member or Manager Phone Number:

Area CodePhone Number
Email
example@example.com
Does this individual have an ownership interest or right in the LLC?
Property Maintenance / Code Contact
Name of Individual / Representative / Employee:

First NameLast Name
Title / Position:
Title / Position
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email:
example@example.com
Does this person have the authority and ability to repair, maintain, or otherwise remedy a problem or municipal code violation concerning the property?

PART 4 — ADDRESS CONFIDENTIALITY PROGRAM
Are you a participant in Pennsylvania's Address Confidentiality Program under 23 Pa.C.S. § 6703? IF YES: You may not be required to provide your actual address or have your actual address disclosed under 68 Pa.C.S. Chapter 25. Contact the Delaware County Board of Assessments for instructions regarding an alternative address/contact procedure.
PART 5 — CERTIFICATION

I certify that the information provided on this form is true and correct to the best of my knowledge.

I understand that, pursuant to 68 Pa.C.S. § 2505(b), if contact information submitted under Chapter 25 changes, the real property owner or the owner's representative must provide current information to the Chief Assessor within 30 days.

I further understand that 68 Pa.C.S. § 2507 authorizes Delaware County to levy a fine of up to $500 against a real property owner or owner's representative who intentionally or knowingly:

1. Provides false or incorrect contact information; or
2. Fails to update required contact information as required by Chapter 25.
Printed Name:

First NameLast Name
Title / Capacity (If applicable):
Title / Capacity
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:

Area CodePhone Number
Email:
example@example.com

You answered YES to the following question:

Is this property owned and occupied by an individual's principal residence and domicile?

If you made a mistake, please start over
Should be Empty: