Special Assessment Disclosure

Special Assessment Disclosure
Please review and acknowledge the details of the special assessment for your property.
Property Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Owner's Full Name
First NameLast Name
Owner's Email Address
example@example.com
Assessment Amount (USD)
Assessment Due Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Special Assessment
How clear was the explanation of the assessment?
Please indicate your understanding of the following aspects of the special assessment.
Rows Fully Understand Somewhat Understand Do Not Understand
Assessment Purpose
Payment Terms
Consequences of Non-Payment
Have you previously paid a special assessment for this property?
Additional Comments or Questions
Signature of Owner
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