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2. Instructions and Purpose
4. Purpose
   This form may be used by a Landlord to authorize an agent to complete and file Richmond Rent Program forms on behalf of the Landlord.
6. Property Information
8. House Number*
9. Street Name*
10. Street Type*
    -- Select One --AlleyAvenueBoulevardCourtCircleDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSquareTerraceWay
11. Apt #
13. City*
14. State*
15. Zip*
17. Assessor Parcel Number (APN)*
19. Agent Authorization
21. Owner (Name on Title) Information
23. First Name*
24. Last Name*
26. Street Number*
27. Street Name*
28. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSquare TerraceWay
29. Apt #
31. City*
32. State*
33. Zip*
35. Owner Phone*
36. Owner Email*
38. Declaration
40. Declaration: I am the owner of the property identified above. I hereby authorize and appoint the following agent to complete and execute, under penalty of perjury, the Richmond Rent Program Enrollment and Rent Increase forms for this property. I agree to be bound by each document filed by this person to the same extent as if I had completed the document and executed it under penalty of perjury myself.
42. Owner Signature (Please Type Full Name as it Appears on This Form)*
43. Signature Verification*

    1. By checking this box, you certify this is your valid signature for all legal purposes.
45. Authorized Person and/or Property Management Company
47. Authorized Agent First Name*
48. Authorized Agent Last Name*
50. Property Management Company Associated with Authorized Agent (if applicable)
52. House Number*
53. Street Name*
54. Street Type*
    -- Select One --AlleyAvenueBoulevardCourtCircleDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSquareTerraceWay
55. Apt #
57. City*
58. State*
59. Zip*
61. Property Management Phone*
62. Property Management Email*
64. Signature
66. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
68. Owner Signature (Please Type Full Name as it Appears on This Form)*
69. Signature Verification*

    1. By checking this box, you certify this is your valid signature for all legal purposes.
71. Form Resubmission?

    1. Check this box if you are resubmitting this form to correct an error.
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field