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REALTORS® ASSOCIATION OF NEW MEXICOPROPERTY MANAGEMENT AGREEMENT - RESIDENTIAL - 2017

PART I - BROKER DUTIES

As required by New Mexico law, before the time a broker generates or presents any written document that has the potential to become an express written agreement, the broker shall disclose in writing to their prospective customer or client, and obtain a written acknowledgement from their prospective customer or client, showing the delivery of the disclosure of the following broker duties:

A. Honesty and reasonable care as set forth in the provisions of this section;

B. Compliance with local, state, and federal fair housing and anti-discrimination laws, the New Mexico Real Estate Li-cense Law and the Real Estate Commission rules and other applicable local, state, and federal laws and regulations;

C. Performance of any and all written agreements made with the customer or client;

D. Assistance to the broker’s customer or client in completing the transaction, unless otherwise agreed to in writing by the customer or client, including1. 2. Assistance in complying with the terms and conditions of the contract and with the closing of the transaction; if

the broker in a transaction is not providing the service, advice or assistance described in paragraphs D(1) and D(2) above, the customer or client must agree in writing that the broker is not expected to provide such service, advice or assistance, and the broker shall disclose the existence of such agreement in writing to the other brokers involved in the transaction;

E. Acknowledgment by the broker that there may be matters related to the transaction that are outside the associate bro-ker’s or qualifying broker’s knowledge or expertise and that the associate broker or qualifying broker will suggest that the customer or client seek expert advice on these matters;

F. Prompt accounting for all money or property received by the broker;

G. interest that the broker has in the transaction including but not limited to:1. Any written brokerage relationship the broker has with any other parties to the transaction or:2. Any material interest or relationship of a business, personal, or family nature that the broker has in the transaction;3. Other brokerage relationship options available in New Mexico;

H. Written disclosure of any adverse material facts actually known by the associate broker or qualifying broker about the

adverse material facts requiring disclosure do not include any information covered by federal fair housing laws or the New Mexico Human Rights Act;

I. is with the former client’s consent or is required by law;

J. Unless otherwise authorized in writing, an associate broker or qualifying broker shall not disclose to their customer or client during the transaction that their seller client or customer has previously indicated they will accept a sales price less than the asking or listed price of a property; that their buyer client or customer has previously indicated they will pay a

TENANT AND LANDLORD SHOULD ACKNOWLEDGE RECEIPT OF THIS INFORMATION BY INITIALING BE-

RANM Form 6102 (2017 March) Cover Page I ©2007 REALTORS® Association of New Mexico Owner Broker

This copyright protected form was created using Instanet Forms and is licensed for use by Andreas Daddio.


PART II - COVER PAGE

RANM Form 6102 (2017 March) Cover Page II ©2007 REALTORS® Association of New Mexico Owner Broker

1. -action, including compensation from more than one party;

If the Brokerage or Qualifying Broker has a material interest or relationship of a business, personal, or family nature in

2. Property Owner is

Owner Signature Date Time Owner Signature Date Time

BROKER

Firm

Broker is is not a REALTOR®Broker

Signature Date Time



1. PARTIES (“Owner”) and (“Brokerage”) do hereby agree that Broker shall have the exclusive right to rent and manage for Owner the Property

Broker’s services may be performed through one or more authorized agents and any reference to Broker in this

2. RELATIONSHIP -

3. PROPERTY

Address City Zip Code

Legal Description

Or metes and bounds description attached as Exhibit ,

PER NEW MEXICO LAW, THERE MUST BE A SEPARATE PROPERTY MANAGEMENT AGREEMENT FOR

4. TERM , , and will terminate at 11:59 pm Mountain Time on , -nation is given no later than days prior to the end of the Term, as set forth above, this Agreement shall become

5. BROKER OBLIGATIONS AND OWNER’S GRANT OF AUTHORITYmanage the Property and Broker agrees to accept the management responsibilities for the Property which shall include the following:A.

up to $

B. in conducting such due diligence, such as obtaining a criminal background check or credit report, Broker must enter

of the information obtained or if Broker is otherwise prohibited by law from disclosing the information obtained,

(Owner’s Initials)

This form and all REALTORS® Association of New Mexico (RANM) forms are for the sole use of RANM members and those New Mexico Real Estate Licensees to whom RANM

is a registered collective membership mark which may be used only by Real Estate Licensees who are members of the National Association of REALTORS® and who subscribe to

RANM Form 6102 (2017 March) Page 1 of 8 ©2007 REALTORS® Association of New Mexico Owner Broker



C. terms and conditions as set forth in this Agreement and in Exhibit “A” attached hereto;

D. E. Addressing tenant issues and negotiating tenant disputes;F. G.

-

contracts for non-recurring items not exceeding $ H. While tenants are in possession of Property, instituting and prosecuting actions to the extent permitted by law to

-

action against a tenant for damages after tenant has vacated the property;I. Contracting for electricity, gas or water and such other services as necessary or prudent for the operation of the

from the establishment of any such service;J. In regards to Short-Term Rentals, collecting New Mexico Gross Receipts Tax and Lodger’s Tax due on all receipts

6. ADDITIONAL BROKER RESPONSIBILITIESA. Maintain records of owner and tenants;B. C. Provide all requested the following documents to Owner or Owner’s designee after termination of this

Agreement: Residential Rental Application; Residential Rental Agreements; documents on tenants; Other

D.

will -ing, Broker

E. Provide Owner with a monthly accounting and to the extent net funds are available after maintaining cash reserve amounts as provided herein, any proceeds due to Owner on or before the day of each month as provided

i. For Rentals of 30-Days or longer: Broker’s accounting shall include the following: a) the previous month’s balance; b) funds deposited by category; c) funds disbursed by category; d) ending balance, and; e) other:

ii. For Short-Term Rentals (29 days or less): in addition to the accounting requirements as set forth above (Para-graph 6(E)(i)), Broker’s accounting shall also include the following: a) rental income for the month; b) credit

7. EXIGENT CIRCUMSTANCES -vation and safety of Property, to avoid the suspension of any essential service to the Property or to comply with federal state or local law, Broker is authorized by Owner, but is not required, to make such emergency repairs in excess of the




8. OWNER REPRESENTATIONA. Owner has full power and authority to enter into this Agreement;B.

have been furnished to Broker;C.

property for the purposes intended under this Agreement;D. The Property is zoned for the intended use;E.

F. Owner is

G. If this is a Common Interest Community (CIC), the CIC’s Declaration of Covenants, Conditions and Restrictions do

of Owner’s failure to inform Broker of any restrictions on leasing or requirements of management set forth in the

behalf;H.

9. COMPENSATION/FEESA. In return for renting and managing the Property, Owner agrees to pay Broker

plus applicable gross receipts taxes in the following manner:

B. -

C. In the event of termination of this Agreement by Owner for any reason prior to the end of the Term, Owner will pay

i. With respect to existing lease: ii. With respect to renewals: iii. Other:

D. All other fees charged to Owner: E. -

10. FEES RETAINED BY BROKER -wise noted below:

Late Charges: Other: Other:

11. INSURANCEdamage or injury to property or persons which might arise out of the occupancy, management, operation or maintenance




adequate to protect the interests of Owner and Broker, but not less than $

insurance within

12. LEAD-BASED PAINT YES

A. disclosure requirements, Owner shall provide Broker with any and all information known and copies of all reports

B. governed by the Lead-Based Paint Renovation, Repair and Painting Program (“Program”), Owner shall complete (UNLESS OTHERWISE DIRECTED BY THE FORM), RANM Form 5112A, Lead-Based Paint Renovation,

13. COMPLIANCE WITH LAWSthe Property and the rental agreements with tenants, including, but not limited to, New Mexico Real Estate Commission license law and regulations, the New Mexico Human Rights Act, the Federal Fair Housing Act (which prohibits dis-crimination on the basis of race, age, religion, color, national origin, ancestry, sex, sexual orientation, gender identity,

14. OWNER’S OBLIGATIONS.A.

days to deposit funds to

B. smoke detectors CO detectors will be installed in the

C.

D. -

15. TENANT DEPOSITS; REFUND Broker -

indemnify and hold the other harmless from any loss, cost or damage, including reasonable attorneys’ fees, incurred byRANM Form 6102 (2017 March) Page 4 of 8 ©2007 REALTORS® Association of New Mexico Owner Broker



16. SERVICEMEMBERS CIVIL RELIEF ACT

17. FOREIGN OWNERS Yes a corporation or partnership created or organized in a foreign country or under the laws of a foreign country, a foreign

Yes

Failure of Owner to provide IRS Form W-8ECI to Broker will result in Broker withholding thirty-percent (30%) of the -

18. ASSIGNMENTA. This Agreement may none; only with

Owner’s consent; other (list conditions):

B. This Agreement may none; only with Broker’s consent; other (list conditions):

19. LEGAL FEES -

20. HOLD HARMLESS CLAUSE -

assumes no liability for violations of environmental or other regulations which may become known during the Term of

the Property regardless of who hires such persons and Owner agrees to indemnify, defend and save Broker harmless

liquid-waste system, unless otherwise agreed to in writing, Broker will not be responsible for any maintenance of such




21. ATTORNEYS’ FEES

22. MEDIATION-

atory cannot be agreed on or mediation is unsuccessful, the parties may enforce their rights and obligations under the

23. ENTIRE AGREEMENT

24. FORCE MAJEURE -ment if the delay or failure is caused by any circumstance beyond their reasonable control, including but not limited to,

25. LAW AND JURISDICTION

26. SEVERANCEof competent jurisdiction, such provision shall be severed and the remainder of the provisions hereof shall continue in

27. TIME IS OF THE ESSENCE

28. ADDITIONAL TERMS

29. NOTICES AND DEMANDS -ment shall be addressed as follows or at such other address as Owner and Broker individually may specify hereafter in writing:

Broker: Address City ZIP Code

Owner: Address City ZIP Code

Copy to: Address City ZIP Code

-

-sonal delivery thereof or forty-eight (48) hours after having been deposited in the United States mails or as evidenced




BROKER

Property Management Firm

Broker is is not a REALTOR®Broker Name (Print)

Broker Signature Date Time

Email Address

Broker Address City ZIP Code

Broker Home Phone Broker Cell Phone Broker Business Phone Broker Fax

OWNER Owner Name(s) (Print)

Owner Signature Date Time

Owner Signature Date Time

Email Address

Owner Address City ZIP Code

Owner Home Phone Owner Cell Phone Owner Business Phone Owner Fax

BROKER MUST PROVIDE A FULLY-EXECUTED COPY OF THIS AGREEMENT TO THE OWNER AFTER OB-




EXHIBIT A - PROPERTY INFORMATION

OWNER NAME: PHONE NUMBER(S): PROPERTY ADDRESS:

Existing Tenant Name: Home Phone: Work Phone:

PROSPECTIVE TENANTS/LEASES: Minimum $ Maximum

Acceptable Lease Term: Minimum MaximumAcceptable Renewal Term: Minimum Maximum

WATER SOURCE: City If well, please check well type: Individual Domestic Shared Domestic OtherLimitations or restrictions on use:

LIQUID WASTE: City Sewer -

PREFERRED NUMBER OF OCCUPANTS: The Department of Housing and Urban Development (HUD) has taken the position that owners and managers may develop and implement reasonable occupancy requirements based on factors such

that, in connection with a complaint alleging discrimination on the basis of familial status, the Department will carefully

WILL PETS BE CONSIDERED YES

SECURITY/DAMAGE DEPOSIT: Broker will collect the equivalent of one month’s rent other amount $

LAST MONTH’S/PREPAID RENT: Broker will will not collect an additional one month’s rent from Tenant to be

OWNER’S INSURANCE: Insurance Name: Insurance Agent Name: Policy #

TENANT’S INSURANCE: Owner does does not require Tenant(s) to obtain and maintain for the duration of the

SMOKING: Smoking is

MEDICAL MARIJUANA: Owner will If Owner will allow smoking, Owner will -

IF APPLICABLE:MAILBOX NUMBER: PARKING SPACE NUMBER: GATE CODE: ALARM COMPANY AND CODE: RANM Form 6102 (2017 March) Page 8 of 8 ©2007 REALTORS® Association of New Mexico Owner Broker


OWNER INFORMATION FORM Please complete as accurately as possible

Owner(s) Legal Name(s):

Primary

Secondary

Owner(s) Mailing Address:

Street/PO Box

City/State/Zip Code

Property Address:

Street/PO Box

City/State/Zip Code

E-Mail Address:

Primary

Secondary

Phones:

Home ( )

Cell-Primary ( )

Cell-Secondary ( )

Office ( )

Other ( )

SSN or EIN#

Insurance

Company

Agent Name

Agent Phone ( )

Agent Email

Policy#

Expiration Date

Liability Limit

Is Property In A Trust (Circle one) Yes No

If Yes: Name of Trust

Trustee(s) Names

Contact Information

Telephone ( )

Email

TURQUOISE TRAIL BUSINESS PARK

21 BISBEE COURT, SUITE F SANTA FE, NM 87508

PHONE: 505.375-1311 FAX: 505.375.1311

WWW.PIÑONPROPERTIES.COM

Properties

Piñon

NEW OWNER CHECKLIST

Very Important: In order to market and manage your property as effectively as possible, it is very important that we have all current information and documents related to the Owner and the Property itself. Please note the following requirements and, wherever possible, complete the information as quickly and accurately as possible.

□ Owner Information Worksheet

□ Property Information Worksheet

□ Property Management Agreement (signed and dated)

• Please sign/date/time both the Broker Disclosure and the Property Management Agreement

• Initial at bottom of each page by “Owner”

□ Lead Based Paint Disclosure

• This only applies if your property was built prior to 1978. If you are not sure, please fill this form out to the best of your knowledge.

□ Utilities

• It is essential that you keep all utilities connected and in your name. This will allow us to perform any needed repairs, and will enhance our ability to show and market the property. This is also very important for protection of pipes and plumbing during cold weather

□ PNM Landlord Standby Agreement (if applicable)

• This will cause PNM to transfer service from the tenant to your account automatically when they notify PNM to discontinue service

• This will allow us to contact PNM on your behalf

□ NM Gas Company Landlord Standby Agreement (if applicable)

• This will cause NMGC to transfer service from the tenant to your account automatically when they notify NMGC to discontinue service

• This will allow us to contact NMGC on your behalf

□ IRS Form W-9

• This is required by the IRS so that we can issue you the 1099 at year-end

□ Authorization for ACH Transfer

• This form authorizes us to make automated monthly deposits to your designated bank account

□ Keys, Remotes and Gate Cards to Property

• We need at least one key from you for each door lock and keep 3 keys for use; provide 2 garage door openers (if applicable), provide 3 gate cards and duplicates of any other locks (like sprinkler timers, basements, sheds, etc.)

□ Insurance

• A copy of the declaration page is required for our files, and Pinon Properties must be listed as an additional insured on the policy

• Your policy should provide minimum protection of $500,000

□ Occupied Properties

• We will need a copy of the current lease

• You will also need to forward the tenant’s security deposit so that it can be held in our trust account

□ Reserve Deposit per Property Management Agreement

• This deposit is needed to establish your repair reserve fund. This also complies with the NM Real Estate Commission rule governing broker trust accounts, which are not allowed to be in a deficit balance. The funds are yours and will be returned to you at the termination of the Management Agreement

□ Leasing Commission & Set-Up Fee per Property Management Agreement

• The set-up fee allows us to input all your information into our property management system. We must receive this prior to marketing the property

• The leasing commission will be equal to a percentage of the first month’s rent, as specified in the management agreement. This allows us to market and place tenants. Can be withheld from first month’s rent.

21 Bisbee Court, Suite F Santa Fe, NM 87508

(505) 375-1311

Recurring Payment Authorization Form

Schedule your monthly payment to be automatically deposited to your bank account. Just complete and sign this form to get started! Recurring Deposits Will Make Your Life Easier:

• It’s convenient (saving you time and money) • Your deposit is always on time (even if you’re out of town) • Your payment does not get lost in the mail

• It also makes it more efficient for us to pay you Here’s How Recurring Deposits Work:

You authorize regularly scheduled deposits to your checking/savings account. A notice for each deposit will be emailed to you and the deposit will appear on your bank statement as an “ACH Debit.” You can cancel this deposit at any time. The payment amount may vary due to activity on your account.

Please complete the information below:

I ____________________________ authorize Pinon Properties to deposit my monthly owner (full name)

payment by the 10th day (subject to weekends or holidays) of each month to the account below.

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

Checking/ Savings Account

Checking Savings

Name on Acct ____________________

Bank Name ____________________

Account Number ____________________

Bank Routing # ____________________

Bank City/State ____________________

You may, but are not required to attach a copy of a voided check or deposit slip to the account you want credited. If you choose not to include such a copy, please make sure that you are providing the correct information (routing & account numbers) to avoid not receiving the deposit on time or correctly. You may also call us at the phone number above if you want us to take the information over the phone.

SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Pinon Properties in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next payment date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

NMGC 756-426 01/16

NEW MEXICO GAS COMPANY USE ONLY:

Customer Account # _________________________________

Contract Account # _________________________________

Date Received: Credit Approval Date: Date Effective: Initials:

LANDLORD STANDBY

SERVICE AGREEMENT

THIS LANDLORD STANDBY SERVICE AGREEMENT (“Agreement”) is made by and between New Mexico Gas

Company (“NMGC”), and ______________ ______(“Landlord”) (each a “Party” and collectively, the “Parties”).

Section I - Recitals

A. Landlord owns certain real property, as listed on Exhibit A attached to this Agreement (“Property”), in NMGC’s service area.

B. NMGC is the utility company authorized to provide gas services to the Property.

C. Landlord desires gas services to the Property to continue uninterrupted when a person(s) or entity (“Tenant”)

who is leasing or otherwise inhabiting the Property requests that the gas services in Tenant’s name be

discontinued, an arrangement referred to as “Landlord Standby Program”.

Section II - Agreement

NOW THEREFORE, New Mexico Gas Company and Landlord agree as follows:

A. NMGC agrees not to terminate gas services to the Property when a Tenant requests that gas services in Tenant’s

name be discontinued. NMGC will instead transfer responsibility for gas services at the Property into the Landlord’s

name and account as of the date such services are scheduled to be discontinued under Tenant’s name. Landlord

agrees to pay any outstanding bills Landlord may owe to NMGC prior to entering into this Agreement. Landlord

agrees that the gas services will remain in Landlord’s name until a new Tenant requests gas services to be placed

into his or her name, or until Landlord requests NMGC discontinue gas services. See Exhibit B.

B. Landlord shall be liable for all bills for gas services provided to the Property which are incurred while gas service

is in Landlord’s name.

C. NMGC is not responsible for a Tenant’s delay in, or failure to, place service in Tenant’s name.

D. If there is more than one Property, or more than one unit per Property, each unit/Property must be separately

metered.

E. NMGC may unilaterally terminate this Agreement if Landlord fails to pay any billed charges for gas services in

Landlord’s name by the relevant due date of the bill.

F. Landlord may not request to disconnect gas service that is in a Tenant’s name.

G. This Agreement DOES NOT automatically terminate if Landlord sells or otherwise transfers ownership of the

Property. Landlord will remain liable for all charges related to gas services in Landlord’s name to the Property

until such time Landlord contacts NMGC to terminate this Agreement.

NMGC 756-426 01/16

Section III – Governing Provisions

A. Term

This Agreement shall commence no later than five (5) business days after Landlord’s credit approval is verified and

shall be effective for each property listed on Exhibit A until the Landlord provides notice to NMGC that a listed

property is no longer subject to the Agreement.

B. Charges and Fees

Landlord shall be charged all applicable fees to initialize gas services if gas services are discontinued prior to

NMGC and Landlord entering into and executing this Agreement.

C. Notice to Discontinue Services for Non-Payment

1. NMGC shall not be required to notify Landlord in advance of any Tenant’s request to discontinue gas service at

the Property.

2. The obligations of the Parties under this Agreement are limited to instances where a Tenant requests gas services

to be discontinued, and does not extend to instances where a Tenant’s services are discontinued for non-payment.

NMGC will, however, attempt to notify Landlord of any impending discontinuance of gas service for non-

payment if an Authorization for Information Disclosure Form is signed by the Tenant and on file with NMGC.

This provision shall apply only in instances where the Tenant who has signed the Authorization for Information

Disclosure Form is the same person(s) who has requested and receives gas services for the same address. See

Exhibit B (Part 1).

D. Request for Information

Landlord must submit a request to NMGC, for any updates or changes, including but not limited to, mailing address

changes, phone number updates, or any other amendments or modifications to information provided to NMGC.

E. Limitation on Damages

Landlord and NMGC agree that neither Party shall be liable to the other for, and waives all, incidental or

consequential damages arising out of or related to services provided under this Agreement.

F. Termination

Either Party may terminate the Agreement by providing three (3) business days prior written notice of termination

to the other Party. Such termination shall not change or modify the obligations of Landlord for any gas services

rendered on and prior to the effective date of termination.

This Agreement and all provisions shall be binding upon the Parties, their executors, successors, and administrators and

permitted assignees.

LANDLORD: NEW MEXICO GAS COMPANY:

Signature: Signature:

Name (print): Name (print):

Date: Date:

LANDLORD INFORMATION:

Mailing Address:

Name:

Street:

City: State: Zip Code:

Daytime Telephone Number: ( ) Evening Telephone Number: ( )

Fax Number: ( ) Email Address:

NMGC 756-426 01/16

LANDLORD STANDBY

SERVICE AGREEMENT

EXHIBIT A

Please list the service address for each Property to be included in the Landlord Standby Program. If you would

like to have service turned on at a property currently unoccupied, please indicate below. If you would like services

transferred from an account currently active in previous owner/landlord name, please provide the name of the former

owner/landlord .

Rental Property Address Turn On Rental Property Address Turn On

Yes

No

Gas

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

EXHIBIT B (PART 1)

AUTHORIZATION FOR INFORMATION DISCLOSURE FORM

I, _____________________________________, hereby authorize New Mexico Gas Company to notify the Landlord if

(Print full name)

gas service is scheduled to be discontinued for non-payment at the following address:

________________________________________________________________________.

_____________________________________________

Tenant Signature (Required)

EXHIBIT B (PART 2)

REQUEST TO DISCONTINUE/FORCE OFF GAS SERVICE

This request will turn off the gas service but will not terminate your Landlord Standby Service Agreement.

To terminate your contract or properties under the contract, please complete and return the Termination of Landlord

Standby Service Agreement form.

Landlord/Owner: ______________________________________________________________

For Property located at: _________________________________________________________

Please issue a discontinuance of service for gas service effective (Please allow 3 business days):

Date: _____________ (Request will not be executed if a new Tenant places service in their name within this

period.)

Signature of Landlord or Agent (Required)

NEW MEXICO GAS COMPANY USE ONLY:

Customer Account # _________________________________

Date Received: ___________ Date of Service Order: ___________ Initials: ________

NEW MEXICO GAS COMPANY

Attn: Landlord Standby Dept.

P.O. Box 97500

Albuquerque, NM 87199-7500

TERMINATION OF LANDLORD STANDBY SERVICE AGREEMENT

This is to notify New Mexico Gas Company that I/we are requesting to terminate the Landlord Standby Service Agreement

for the following Property(ies) effective as of .

List all Property subject to the termination:

Service Address(es): Account Number(s):

I/We understand that New Mexico Gas Company requires three (3) business days’ notice prior to

termination of the Agreement.

Please accept the following name and signature to terminate the Landlord Standby Service Agreement.

Name of Owner: Name of Management Company:

(if applicable)

Please provide forwarding address and phone number for Landlord (property owner).

I/We understand that the Landlord Standby Service Agreement remains valid and in full force for any Property not

set forth above or in a separate termination document.

Signature:



P.O. Box 97500


If gas service is currently ON in the Landlord’s name, do you wish to have the service turned

OFF? Yes No

LANDLORD STANDBY AUTHORIZATION FOR THIRD PARTY

I, _____________________________________________________, owner(s) of the Property located at

(Print Full Name)

(Street Address(es) and All Units Associated with the Property)

(City) (State) (Zip Code)

do hereby give authorization to to manage

(Name of Representative/Agent/Management Company)

my account(s) with New Mexico Gas Company on my behalf.

Name of Representative/Agent/Management Company

Mailing Address

City State Zip Code

Phone Number Fax Number

Email Address

Owner’s Name

(Print Full Name)

Mailing Address of Owner

City State Zip Code

Phone Number Fax Number

Email Address

Signature of Owner Second Owner Signature (if applicable)

Representative or Acting Agent (print) Signature of Representative or Acting Agent



P.O. Box 97500


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