In accordance with Part XIV, Section 2 (c) of Senate Bill 92, please provide the
following information:

Agent's Name:                 __________________________________________________________

Agent's Mailing Address:      __________________________________________________________

                              __________________________________________________________

                              __________________________________________________________


Rental property location: Attach a separate list showing:

	Owner's Name
	Owner's Mailing Address
	Rental Property Location

By listing this property, you are indicating that it is AVAILABLE for rent.

This is to certify that the information provided above, to the best of my knowledge and
belief, is true and provided in good faith.


_______________________________________________________         __________________________
Signature                                                       Date