Communication Designee Form
Purpose: Primary Applicants may designate a third party, known as a Communication Designee, to
obtain information about their program status in person, by phone, by email, and by mail. However,
Communication Designees are not authorized to make any decision on behalf of the Primary Applicant,
or to sign the grant agreement or any other program documents or affidavits on behalf of the Primary
Applicant unless they also hold a valid Power of Attorney. If an individual currently holds Power of
Attorney for a Primary Applicant, that POA does not need to complete this form. Instead, they should
provide the Program with the executed Power of Attorney document.
Instructions: The Primary Applicant and Communication Designees should provide their full legal
names, addresses, and phone numbers (with area codes). In order to be valid, this form must be
signed and dated by both the Primary Applicant and Communication Designee. A separate form must
be completed for each Communication Designee, i.e., multiple Communication Designees may not be
authorized in a single form.
Warning: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for
knowingly and willingly making false or fraudulent statements to any department of the United
States government.
I hereby certify and affirm that I, __________________________, am an owner of the damaged property
located at: ____________________________________________ _____________. I do hereby authorize
__________________________ to be my Communication Designee in connection with the ReBuild NC
Application ID Number _______________. In addition to providing the Application ID Number, the
following code word will be used to ensure the identity of the Communication Designee: _____________.
My Communication Designee’s address is: _________________________________________________,
and daytime phone number is ________________________ . This Communication Designee assignment
will be valid until I indicate otherwise to ReBuild NC.
Primary Applicant Signature Communication Designee Signature
Primary Applicant Printed Name Communication Designee Printed Name
Signed ____ day of ______________, 20 ____. Signed ____ day of ______________, 20 ____.
ReBuild NC is a program of the North Carolina Office of Recovery and Resiliency
Last Updated: April 23, 2020
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