HomeMy WebLinkAboutFamily Exempt AffidavitAFFIDAVIT OF PROPERTY OWNER
FOR A FAMILY MEMBER EXEMPTION
Property owners claiming the relative/step-relative exemption shall complete the Affidavit of Exemption.
Property Owners eligible for a Family Exempt Rental License who submit this form with a complete Rental
Housing License Application receive a reduced rental occupancy license fee.
That I am the legal owner of a certain real property located at
_______________________________________________________________________________________
That I am aware of the City of Columbia Heights's ordinance pertaining to the annual licensing of all rental
dwelling or rental dwelling units. This includes vacation rental dwellings and dwellings for hire where all
units are occupied by the owner or persons who are the owner's child, stepchild, daughter-in-law, son-in-
law, parent, stepparent, parent-in-law, grandchild, grandparent, brother, brother- in-law, sister, sister-in-
law, aunt or uncle.
I am eligible for the Family Rental Exemption licensing fee because ALL renters residing at this rental
property are related to me as a child, stepchild, daughter-in-law, son-in-law, parent, stepparent, parent-in-
law, grandchild, grandparent, brother, brother- in-law, sister, sister-in-law, aunt or uncle.
If family member(s) vacate the property and thereafter I desire to rent the property to a non-family
member, I understand that I must obtain the appropriate rental license from the City of Columbia Heights
prior to the occupancy of the tenant.
That the failure to comply is in violation of Chapter 5A of city code.
The following family members reside in the rental property:
Full Legal Name Relationship Date of Birth
In the witness whereof, I certify under penalty of perjury under Minnesota law that I know the contents of this
affidavit signed by me and that the statements are true and correct. I further acknowledge that if, in the future,
persons other than listed in this Affidavit, reside/occupy this property changes to that of an occupied rental
dwelling. I will license this property in accordance with the Code of Ordinances of the City of Columbia Heights.
Property Owner:
Owner Signature:
STATE OF MINNESOTA
COUNTY OF ANOKA
This instrument was acknowledged before me
on _____________ (date) by ___________________.
Notary Public Signature:
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