Building Division
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
AFFIDAVIT OF HOUSE RENTAL REGISTRATION REMOVAL
STATE OF NEW YORK
ss.:
COUNTY OF SUFFOLK
I, _____________________________, residing at ____________________________________________,
___________________________________ ,being duly sworn, deposes and says:
That I am the present owner of the premises located at:
Address: ________________________________________ Hamlet: ____________________________________
State: ________________________________________ Zip Code: ___________________________________
Section: _________________________ Block ____________________________ Lot ______________________
That I no longer rent said premises, Rental Registration # _____________________
I understand that if I select to rent said premises again that I will be required to comply with the
Neighborhood Preservation Act pursuant to Chapter 82 of the Code of the Town of Brookhaven, informally known
as the “Rental Law”.
I attest to this document with full understanding that I am swearing under oath to this fact and that swearing
falsely or giving a misleading or untrue statement subjects me to prosecution under New York State Penal Law
Section 210.5.
Attachment
DATED: ______________________
______________________, New York
________________________________
Signature (Owner)
Sworn to before me this ___ day
of __________________ , 20 ___ . Email: ________________________________
___________________________
Notary Public
TAX MAP NUMBER __ __ __ __-__ __ __.__ __-__ __.__ __-__ __ __.__ __ __
2018
