Clearwater Right of Entry Form

Clearwater Right of Entry Form

Only ONE form is required per community to be completed by the authorized agent/representative of each association.

Select property type:*

Commercial Property

Condo

City Utility Account Number*

Address of Location*

Ownership Interest and Grant of Right of Entry for Debris Removal

The undersigned hereby certifies they/he/she are/is (choose one):*

The Property Owner(s)/agent authorize(s) the city of Clearwater, the State of Florida, and the United States of America, their respective agents, successors and assigns, contractors and subcontractors (collectively, the "Governments/Contractors") to have the right of access and to enter the property above specified for purposes of performing debris removal as it is a public health and safety threat to the general public resulting from the declared major disaster.

Governments/Contractors will perform the following work: Remove debris from the Property

I certify that I am: (chose one)

The authorized agent of the Property Owner.

The owner(s) with authority to grant access to the property at...

Enter Address*

Government Not Obligated; No Expense Except For Insurance Proceeds

The Property Owner/agent understands that this Right-of-Entry does not obligate the Governments/Contractors to perform debris removal. Governments/Contractors will access the property under this ROE if the work has been determined necessary in accordance with Federal, State, or local regulations. The Property Owner(s) will not be charged for the work conducted by Governments/Contractors. However, if the Property Owner receives insurance proceeds or compensation from other sources for debris removal, the Property Owner's obligation is set out in the section below, entitled "Avoidance of Duplication of Benefits…."

I have read and agree:*

Yes

Avoidance of Duplication of Benefits: Reporting Debris Removal Money Received

Property Owner/agent has an obligation to file an insurance claim if coverage is available. Property Owner/agent understands and acknowledges that receipt of compensation or reimbursement for performance of the aforementioned activities from any source, including Small Business Administration, private insurance, an individual and family grant program or any other public or private assistance program could constitute a duplication of benefits prohibited by federal law. If the Property Owner/agent receives any compensation from any source for debris removal on this Property, the Property Owner/agent will report it to the Clearwater Solid Waste/Recycling Department.

I have read and agree:*

Yes

Release of Insurance Information

If insured, the Property Owner/agent authorizes its insurer to release information relating to coverage and payments for debris removal activities to the City/County identified herein and/or to the State of Florida.

If you are insured, the insurance policy information will be required.

Are you insured?*

Yes

Insurance Company*

Claim #

If a claim has been filed, please provide the claim number.

Policy #*

Acknowledgment of Prohibition on Fraud, Intentional Misstatements

The Property Owner/agent understands that an individual who fraudulently or willfully misstates any fact in connection with this agreement may be subject to penalties under state and federal law, including civil penalties, imprisonment for not more than five years, or both, as provided under 18 USC 1001.*

Yes

Signature and Date

Property Owner(s) or Authorized Agent and Mortgage/Lien Holder(s)

For the considerations and purposes set forth herein, I/we hereby set my/our hand(s) and seal(s) this day,*

Property Owner/Authorized Agent Name*

Property Owner/Authorized Agent Phone*

Phone

Property Owner/Authorized Agent Email*

How would you like to sign this form?*

Type Signature

Upload Photo of Signature

Please type your signature below:*

Please upload a photo of your signature below:*

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Privacy Act Statement

The Property Owner / Owner's Authorized Agent acknowledge(s) that information submitted will be shared with other government agencies, federal and non-federal, and contractors, their subcontractors and employees but solely for purposes of disaster relief management to meet the objectives of this Right-of-Entry. This form is signed to allow access to perform debris removal operations on the above-mentioned property, and to authorize the release of insurance policy/claim information.

I have read and agree:*

Yes

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