City of Temple Terrace Customer Service

Authorized Agent Affidavit

2. THIS FORM MUST BE PRINTED, SIGNED AND BROUGHT TO THE COMMUNITY DEVELOPMENT OFFICE IN CITY HALL
4. Authorized Agent Affidavit
6. The undersigned, _____________________ , as owner or officer of the owner of the real property located at _______________________________________; Folio No. _____________________ (“Property”) hereby appoints and grants authorization to ___________________________________________ (“Authorized Agent”) to act on behalf of the owner with the City of Temple Terrace Community Development Department and other members of City staff while conducting activities related to the development of the above Property, including, but not limited to filing applications and obtaining development orders and permits. These activities specifically include signing all documents on behalf of the owner. Authorized Agent is to be considered an agent of the owner’s business and therefore the signature of said agent is binding on the owner and causes the owner to assume all responsibilities connected to or associated with the signature as they may relate to the Property. The undersigned owner hereby relieves the City of Temple Terrace Community Development Department of, and agrees to hold the City of Temple Terrace Community Development Department harmless from, any and all responsibility, claims or other actions arising from or related to the Department’s acceptance of the Authorized Agent’s signature for permit/application and other development related activities. The undersigned owner understand that it is his/her sole responsibility to grant and terminate any such authorization and to ensure that the Department receives timely notice of any such grant or termination.
8. OWNER
9. AUTHORIZED AGENT
11. Owner's First and Last Name
12. Authorized Agent's First and Last Name
14. Owner's Company and Title
15. Authorized Agent's Company and Title
17. Signature of Owner
    ____________________________________________
18. Signature of Authorized Agent
    ____________________________________________
20. Notary for Owner's Signature
21. Notary for Agent's Signature
23. State of _________________ County of ___________________
24. State of __________________ County of ___________________
26. The foregoing was acknowledged before me this ___________ day of _____________________, _____________, by _________________________, who is personally known to me, or who produced ______________________________________________ as identification.
27. The foregoing was acknowledged before me this ___________ day of _____________________, _____________, by _________________________, who is personally known to me, or who produced ______________________________________________ as identification.
29. Notary Public Signature
    ____________________________________________
30. Notary Public Signature
    ____________________________________________
32. Notary Name (Print)
    ____________________________________________
33. Notary Name (Print)
    ____________________________________________
35. My Commission Expires:
    ____________________________________________
36. My Commission Expires:
    ____________________________________________
38. (SEAL)
39. (SEAL)
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40. Print Only

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