AGENCY AUTHORIZATION FORM - HH-ERF & ESG
All Landlords must complete this form. If you are not authorizing another agent, list your own name as the Authorized Agent.
The undersigned participant (Property Owner) in the Healthy at Home Eviction Prevention Fund and/or the Emergency
Solutions Grant Program authorizes the person(s) listed below [Authorized Agent(s)] to execute on Property Owner’s
behalf any and all documents required by KHC in the administration of the Programs; except, the Authorized Agent(s) may
NOT use the authority granted herein to amend or change the name of the entity receiving payment.
Please select ONE:
I am a sole proprietor/individual property owner.
Ownership is a part of a Corporation, Cooperative, Partnership, or Limited Liability Company (LLC)
Company Name:
Property is managed by a Property Management Company who acts on behalf of the Legal owner.
(Must provide a copy of the Management Agreement along with this completed form).
Property Management Company Name:
AUTHORIZED AGENT(S):
Print or type name Signature (management representative or authorized
individual)
Print or type name Signature (management representative or
authorized individual)
Phone Number Email Address
This authorization shall remain in full force and effect until terminated or amended in writing by Property Owner.
Note: The spouse of a sole proprietor/individual property owner must also be listed as an authorized agent to gain access to account
information.
If an individual property owner, sign below: If a corporation, Limited Liability Company or partnership,
print legal business name below and sign as indicated:
Signature
Business Name
Print Name By:
Print Name
TITLE:
Signature
Phone Number (if different from above) Email Address (if different from above)
