FLORIDA MOBILE HOME RELOCATION CORPORATION

[Pages:1]FORM 1009: ACKNOWLEDGMENT BY PARK OWNER WHEN A HOME IS ABANDONED FLORIDA MOBILE HOME RELOCATION CORPORATION (Page 1 of 1)

Pursuant to Sections 723.0612, F.S., the Florida Mobile Home Relocation Corporation requires that a signature be obtained from the mobile home park owner in order for the applicant to receive payment from the Corporation for abandonment of a mobile home.

FAILURE TO COMPLETE ALL SECTIONS MAY RESULT IN THE REJECTION OF YOUR APPLICATION.

SECTION 1: Name of Applicant(s):

Address You Are Leaving:

Lot Number of Mobile Home to be Abandoned:

City:

State:

Zip Code:

Phone Number:

Check One: Single-section

Multi-section

Name of the Mobile Home Park:

SECTION 2: CHECK ONE ONLY (If you cannot obtain the park owner's signature, you MUST complete the Section below labeled "B")

A.

I was able to receive the mobile home park owner's signature.

By signing this form, I hereby acknowledge the abandonment of the mobile home owned by the applicant referenced above and agree to make payment to the Florida Mobile Home Relocation Corporation for the abandonment of the above referenced mobile home in the amount required by Florida Law.

Park Owner's Signature

B.

I was unable to receive my mobile home park owner's signature after the following attempt:

Date Attempted to Deliver:

Person Delivered to or Contacted:

Pursuant to s. 723.0612 (10), Florida Statutes, it is unlawful for any person or his or her agent to file any notice, statement or other document required under this section which is false or contains any material misstatement of fact. Any person who violates this subsection commits a misdemeanor of the second degree punishable as provided in s. 775.082 or s. 775.083.

(Signature of Applicant)

(Date)

(Signature of Applicant)

(Date)

RETURN APPLICATION TO: FMHRC, P.O. Box 7848, Clearwater, FL 33758

FORM 1009 ? ACKNOWLEDGMENT BY PARK OWNER WHEN A HOME IS ABANDONED (Revised 11/5/2015 Supersedes all previous Forms)

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