OWNER AGENT CERTIFICATION- REV. 201806 PAGE 1 OF 1
Development
Services
Owner’s Agent Certification
Applications for development activities may be submitted by the recorded property owner(s) or the
owner’s agent(s). Effective October 1, 2009 agents will need to provide a completed copy of this agent
certification when submitting applications on behalf of owners. Signatures obtained by facsimile will be
accepted. Bastrop County may contact property owners by phone, email or U.S. mail to validate signatures.
Appraisal District Property ID(s)
Property Address(es)
Owner’s Name(s)
Owner’s Contact Address
Owner’s Contact Phone(s)
Owner’s Contact Email
Agent’s Name(s)
Agent’s Contact Address
Agent’s Contact Phone(s)
Agent’s Contact Email
Certification Statement
I (owner) certify I have assigned
(agent) to represent my interests
for the purpose of obtaining county services associated with (initial all that apply):
______ 9-1-1 Address Assignment
______ Development Permit
______ Drivewa
y Permit
______ On-S
ite Sewage Facility Permit
______ Subdivision
______ Other:
for all parcels listed above. I further declare that this statement is valid until (date) .
I understand that I may repeal this assignment at any time by submitting a written request,
along with a copy of this form, to Bastrop County Development Services, 211 Jackson Street,
Bastrop County, Texas 78602.
Signed this of , 20
Owner’s Signature
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
