Member Contact Information & Authorization Form

Member Contact Information & Authorization Form

Today's Date*

Division - Block - Lot (if multiple, list all)*

Please complete using these examples: 8-135 or 18-1-15 or WS1-1-1. (Only Lots in Divisions 18, WS and ES have a Block #.)

Do you have a Water Connection with LCMC?

Select

Water Account (if multiple, list all)*

Contact Information Confirmation

The Main Contact will receive all communication from LCMC. it is their responsibility to communicate the information with all other owners.

Main Contact Person's Name*

Main Contact Mailing Address*

Please include Street Address, City, State and Zip Code.

Main Contact's Home Phone Number

Phone

Main Contact's Cell Phone Number

Phone

Main Contact's Email Address

Is there a second lessee?*

Select

Second Lessee's Name*

Second Lessee's Home Phone Number

Phone

Second Lessee's Cell Phone Number

Phone

Second Lessee's Email Address

Is there a third lessee?*

Select

Third Lessee's Name*

Third Lessee's Home Phone Number

Phone

Third Lessee's Cell Phone Number

Phone

Third Lessee's Email Address

Is there a fourth lessee?*

Select

Fourth Lessee's Name*

Fourth Lessee's Home Phone Number

Phone

Fourth Lessee's Cell Phone Number

Phone

Fourth Lessee's Email Address

Are there more than four lessees*

Select

If there are more than four lessees on the account

Describe the property

Is vacant

Has a structure but not a dwelling

Has a dwelling

Describe the residential status

Full-time resident(s)

Part-time resident(s)

Recreational resident(s)

Terms and Conditions for Paperless Communication

•By “Opting In”, you are choosing to receive all LCMC communications, including bills and billing related communications, by email whenever possible and will NOT be receiving billing statement(s) or other communications by mail. •Once enrolled in the electronic communication program, you are responsible for ensuring receipt of the email(s). LCMC will send all communication, including bills to the main contact’s email address you provide as the Main Contact's Email Address, and if you fail to receive it, you would still be responsible for complying with any due dates or deadlines. If a payment due is not received or is received after the due date, penalties will apply. •To ensure that we can provide you with accurate billing information, you must update us with any change in your e-mail address by submitting a new Member Contact Information & Authorization Form. •You have the right to withdraw your consent at any time IN WRITING by contacting LCMC@LakeCushmanMC.com or to: 3740 N Lake Cushman Rd., Hoodsport, WA 98548

I (we) wish to receive all HOA communication by:*

Select

I (we) wish to receive all Water communication by:*

Select

Privacy Notice

Washington state law RCW § 64.38.045 requires that Homeowners’ Associations allow all members to inspect any records maintained by LCMC. The law only authorizes LCMC to protect member’s unlisted telephone numbers. Address, phone numbers, e-mail address, financial information and any other information held by LCMC is subject to disclosure upon a member request. LCMC records may contain information that you may feel is private or confidential and which you would like to protect from disclosure. To help you protect your privacy, the LCMC Board adopted Resolution No. 03-17 which provides you the opportunity to be notified if another member requests information about you from LCMC. If you elect to receive notification, a notice will be sent to you via your selected notification preference, notifying you that your information has been requested. You will be given a period of ten (10) business days to seek a protection order from a court prohibiting LCMC from disclosing the information. If you do not provide a valid court order to LCMC within that ten-day period, the information will be provided to the requestor. You are advised to seek the services of an attorney if you wish to protect your information. Any action to protect your information will be at your exclusive cost and expense.

I (we) would like to be notified when someone requests my (our) information.*

Select

Main Contact Account Permissions

By checking the boxes below, you are offering your electronic signature to certify that the above information is accurate and that you are the sole Lessee on the account or have permission from all Lessees on the account to be the Main Contact Person and update the account's Contact Information, E-Communication preference and Privacy Notice Option.

I am the sole Lessee or have permission from all Lessees on the account to be the Main Contact.*

I am the sole Lessee or have permission from all Lessees on the account to update the Contact Information.*

I am the sole Lessee or have permission from all Lessees on the account to update the E-Communication Authorization.*

I am the sole Lessee or have permission from all Lessees on the account to update the Privacy Notice.*

I agree to all the Terms and Conditions set forth in the Member Contact Information & Authorization Form.*

Select

Send me a copy of my responses

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