050619 JP 08/16/04
Landlord / Owner Name: ____________________________________________________________________
I authorize the following person (“Authorized Person”) to act on my behalf:
Name: ___________________________________________________________________________________
Address: _________________________________ Phone: ______________________________
City: _______________________________ State: ____________________ Zip Code: __________
State Reason for Request:
Please indicate where you would like the Housing Authority to direct correspondence.
I would like all correspondence from the Housing Authority to be directed to myself at the existing address
currently on file with the Housing Authority.
I would like all correspondence from the Housing Authority to be directed to the Authorized Person at the
address listed above.
I authorized the person named above to act on my behalf in any communication with the Housing Authority,
both oral and written. I understand that it is my responsibility to communicate with the Authorized Person
about actions he or she has taken on my behalf. I understand that this agreement does not release me from my
responsibility to comply with Section 8 program requirements. I understand that I am responsible for complying
with any and all agreements entered into on my behalf and signed by the Authorized Person.
Additionally, nothing in this agreement prevents me from acting on my own behalf. I understand that I may
continue to sign documents myself. This agreement will not expire unless I notify the Housing Authority in
writing that I would like to cancel it. This agreement is not effective unless the Housing Authority approves it
by signing below.
___________________________________ _________
Landlord / Owner Signature Date
___________________________________ ____________________________ _________
Authorized Person Signature Authorized Person Name Date
___________________________________ _________
Housing Authority Approval Date