Vacant Property/Building Form | Village of Middlefield, Ohio

Section I: Address of Vacant Property/Building (Required)

Street Address*

Section II: Property Owner Information (Required)

(No P.O. Boxes are permitted; must provide a building address.)

If Individual Owner or Designated Agent, please complete the following:

Property Owner's Name*

First Last

Owner's Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Telephone Number*

Cell Number*

Designated Agent's or Contact Person's Name*

First Last

Address*

Street Address Address Line 2 Village State ZIP Code

Email*

Enter Email Confirm Email

Telephone Number*

Fax Number

If Partnership, Corporation, Trust or Other, please complete the following: (Please use the supplemental form to list each additional partner, officer, or trustee.)

Tax ID Number of Partnership or Corporation

Name of Partnership or Corporation

Contact Person

First Last

Title

Designated Agent or Contact Person

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Telephone Number

Fax Number

Section III: Designated Agent / Property Manager

(If owner is further than 25 miles from Middlefield)

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

Section IV: Vacant Building Plan (Required)

I hereby submit a plan of (check one):*

Demolition
Secure Vacancy
Rehabilitation

Description of Work:

Upload plans*

Drop files here or

Accepted file types: pdf, Max. file size: 50 MB, Max. files: 10.

Section V: Proof of Insurance (Required)

If submitting a plan of demolition, please also provide proof of holding in escrow with the Middlefield Village the amount of ten thousand dollars ($10,000). If the amount to be paid into escrow cannot be paid in full, the Village will place a lien on the property for the full ten thousand dollar deposit amount. Escrow funds will be released upon completion of the work or transfer of ownership, provided that all fees have been paid in full. New owners must sign a form accepting responsibility for completing the demolition. Use additional paper to outline further details pertaining to your plan.

Escrow for Demolition

Yes
No

Upload proof of insurance, escrow and/or further details about your plan:*

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 50 MB, Max. files: 5.

Section VI: Fees (Required)

The vacant property registration payment included with this form pertains to the current year of vacancy and is for the...

Registration Fee*

First Year ($200)
Second Year ($400)
Third Year ($800)
Fourth Year ($1600)
Fifth Year ($3200)

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Signed*

First Name Last Name

Date Signed*

Vacant Property/Building Registration Form

Section I: Address of Vacant Property/Building (Required)

Section II: Property Owner Information (Required)

Section III: Designated Agent / Property Manager

Section IV: Vacant Building Plan (Required)

Section V: Proof of Insurance (Required)

Section VI: Fees (Required)

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