060108 052918 BA RA
Tenant Name: ________________________________
I authorize the following person (“Authorized Person”) to act on my behalf:
Person’s Name: ______________________________________ Agency (if applicable):___________________________
Address: ____________________________________ Phone: ________________________
City: _________________________ State: _________ Zip Code: __________
State Reason for Request:
I authorize the above-referenced person to: (tenant must initial):
______ Sign documents on my behalf. This is permitted only if the tenant’s disability prevents them from signing
his/her own name. The Authorized Person must sign their own signature, then print “for [tenant’s name]”
Please provide the name and address of a health care provider or social worker who can verify the disability in the space
below and the Housing Authority will contact this person directly. If you include contact information that is
incomplete or incorrect, this form will be returned to you to complete and/or correct which will delay the
processing of your request. By signing this form, I authorize my health care provider or social worker to release
information to the Housing Authority regarding my disability.
Name of health care provider / social worker:_________________________ Phone:____________________
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. 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. You will be informed of the Housing Authority’s granting, denial, or status of this request within thirty (30) days
of the receipt of this request.
________________________________________ ______________
Tenant Signature Date
________________________________________ ____________________________ _________
Authorized Person Signature Authorized Person Name (Print or Type) Date
________________________________________ ______________
Housing Authority Approval – Administration Department Date
If you have any questions regarding this, please contact the Housing Authority at (831) 454-5955 Monday through Thursday, between
8:00 AM – 4:45 PM.
If the person you would like to be authorized to sign all Housing Authority related documentation on your behalf is the
representative of an advocacy agency, the name and address of that Agency must be noted in the applicable place. If the Authorized
person is a friend or family member, their personal contact information should be included:
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