1-10-2019 BLC
Weatherization Assistance Program
Declaration of Ownership and Occupancy
To be used for occupancy issues where applicant is not the owner of record; and the legal owner is not being
compensated for applicants’ use of property. Proof of ownership must be provided.
Client Name: ____________________________ Approx Date Property was acquired: _______________
Property Address: _________________________ Length of time client has lived at property: __________
City/State/Zip: ____________________________
Name on recorded title: _________________________ Relationship to client: _______________________________
Is compensation being received for Applicant to reside at the property? Yes, No
If yes, explain below why this is not considered as a rental
Check Applicable Circumstance:
Home Owned by a Family Member
Home Owned by Trust
Copy of Trust listing authorized trustees must be attached
Owner Financed Sale
Copy of Contract or sales agreement must be attached
Owner not a U.S. Resident
Other: ___________________________
ief description of circumstances:______________________________________________________________________
By signing this agreement I agree to permit the Agency to undertake weatherization activities allowed by federal law and
regulations as determined necessary by an energy audit conducted by the Agency.
_______________________________ _____________________________________________
Printed name of Owner of Record Signature of Owner of Record
In t
he County of _________________, State of Utah, on this _______ day of __________________, 20_____, before me,
the undersigned notary, personally appeared ____________________, who provided to me his/her identity through
documentary evidence in the form of a ____________________ to be the person whose name is signed on the preceding
document, and acknowledge to me that he/she signed it voluntarily for its stated purpose.
(Notary Public Seal)
Notary Signature