CITY OF MENLO PARK ANNUAL MONITORING CERTIFICATION FORM

ANNUAL MONITORING CERTIFICATION FORM

When you purchased a home and/or received a loan through the City of Menlo Park BMR Program, you agreed to reside in the property as your principal residence for the term of your agreement.

Please complete the following form and upload the required documentation in order to complete the Menlo Park annual occupancy verification. Please contact bmr@menlopark.gov should you have any questions.

Email Address:

First Name:

Last Name:

Phone Number:

Mailing Address:

City:

State:

Zip Code:

Address of Property that has an Agreement with Menlo Park:

Is your property being rented?

How many people live at the property?

List all Current Household Members

Household Member #1 Name

Household Member #1 Age

Household Member #1 Place of Employment

Household Member #1 Address of Employer

Household Member #2 Name

Household Member #2 Age

Household Member #2 Place of Employment

Household Member #2 Address of Employer

Household Member #3 Name

Household Member #3 Age

Household Member #3 Place of Employment

Household Member #3 Address of Employer

Household Member #4 Name

Household Member #4 Age

Household Member #4 Place of Employment

Household Member #4 Address of Employer

Household Member #5 Name

Household Member #5 Age

Household Member #5 Place of Employment

Household Member #5 Address of Employer

Click to upload Evidence of Insurance No file chosen

Click to upload Recent utility bill No file chosen

Click to upload Current mortgage statement No file chosen

Click to a Current form of identification No file chosen

The undersigned declares and certifies the following information under penalty of perjury under the laws of the State of California:

1. Ownership: The owner information listed above accurately reflects the information on title to the Property. Owner has not transferred or encumbered title without providing notice to the City of Menlo Park as required under the Agreement.

2. The Property is being used as a Primary Residence for the homeowner.

3. Owner is in compliance with all other terms and conditions of the restriction agreement.

Is the above referenced property is being occupied as your principal residence?

Is the above referenced property is currently in good repair?

Has the above referenced property been sold, transferred or conveyed to any person or entity since you originally purchase your home? (Including refinancing/HELOCs)

Have you added or subtracted a co-owner, put the home into a trust or changed the manner in which title is held since you originally purchased?

I Acknowledge the information provided is true and accurate as of the date of submittal. Furthermore, I understand that any misrepresentation of the information provided herein, either intentional or negligent, can constitute non-compliance with the terms of the agreement with The City of Menlo Park and could result in default of the agreement. Also, I understand that all the documentation provided is being used to determine compliance with the City of Menlo Park agreement and non-compliance may result in a default of those terms.

Signature: