| A) | 1. | Name and Address of Record Owner of the Premises: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| 2. | Name and Address of Record Owner of the Rental Business: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| B) | | Name and Address of Registered Agent and Corporate Officers of the Said Corporation: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| C) | | Name and Address of Person Authorized to Accept Notices from Tenants and to Issue Receipts therefor and to Accept Service of Process: MUST BE BERGEN COUNTY RESIDENT |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| D) | | Name and Address of Managing Agent: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| E) | | Superintendent, Janitor or Custodian: Name and Address: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| F) | | Name, Address and Telephone Number of Person to Contact in Event of an Emergency: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| G) | | Name and Address of Holder of a Recorded Mortgage: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| H) | | Name and Address of Fuel Oil Dealer: Grade of Oil: |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |
| | _________________________________________________________________________ |