Landlord Report Form


Millersburg Borough Ordinance No. 2-05 requires that all landlord/property owners who lease/rent any property within the Borough of Millersburg provide to the Borough the address of such rental or leased property and the names and other information as required on this form of the tenants of such rented or leased units. All reports required under Ordinance No. 2-05 shall be made within ten (10) days of a change of occupancy, including a vacancy.Print N/A if section(s) 3, 4, or 5 is/are not applicable.

The information requested must be provided in full or the form will not be accepted. Any individual living at this address not listed on this form constitutes a violation of Ordinance No. 2-05 and the landlord/owner may be prosecuted.

This information will be shared with the Millersburg School District Business Office and the Millersburg Borough Police Department.

Earlier versions of this form will not be accepted.

Millersburg Borough
Landlord Report Form
Revised 4.19.2018

Download the form below and fill out the PDF form. When finished, click “submit form” to email the completed form to the Millersburg Borough office.

  • File must be downloaded to your desktop. (Online version will not send.)
  • Fields highlighted in RED are required.
  • If field is not applicable, please type N/A.
  • If room is needed for additional tenant names, please submit a second form.
  • You may also print off the fillable form and mail to the Millersburg Borough office or drop it off.
Landlord Report Form (right click and download to your desktop)

Alternatively, you may pick up a paper form at the Millersburg Borough office, if preferred.