Real Estate Special Assessment Disclosure Form

Real Estate Special Assessment Disclosure Form
Please review and complete this form to acknowledge receipt and understanding of the special assessment related to your property.
Property Owner Full Name*
First NameLast Name
Owner Email Address*
example@example.com
Owner Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Property Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Maintenance/RepairsCapital ImprovementsEmergency AssessmentOther
Special Assessment Details*
Assessment Amount (USD)*
One-time PaymentInstallments (Monthly)Installments (Quarterly)Other

Please indicate your understanding of the special assessment terms below.*

Rows	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
I have read and understood the details of the special assessment.
I understand the payment schedule and amount due.
I acknowledge the reason for the assessment has been explained.

Comments or Questions
Signature of Property Owner (required to acknowledge receipt)*
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