Age Verification Survey Form

Fullerton Fountains HOA Age Verification Survey
Identification of Age Verification Survey Respondent
Enter your name, contact phone numbers and mailing address.
Name
Street
Day Phone #
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)
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City
Night Phone #
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)
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State & Zip
Instructions
Complete all information requested below and submit all required documentation before you
or any new tenant or resident occupies the unit. Failure to submit a fully completed, signed
and documented survey WILL result in the imposition of a fine. Interest is charged on all
outstanding penalties at the maximum allowable rate.
Send documentation to: Fullerton Fountains HOA, c/o Cardinal Property Management, Inc.,
1290 N. Hancock Street, Suite 103, Anaheim, CA 92807, Email: [email protected]
Part I: Identification of Age Verification Survey Respondent’s Residency
I am the current owner of record for the condominium unit listed below. I understand that I am
legally responsible for providing accurate and complete information and documentation to
answer the questions below. If I am not an actual resident of the unit, I understand that I am
legally responsible for providing accurate and complete information and documentation for ALL
residents living in the unit. I understand that there are fines, penalties and interest associated
with my failure to complete this age verification survey by the deadline. I am signing this
document under the penalties of perjury under the laws of the State of California.
Print Name: _____________________________________
Date: _______________________
Signature: _______________________________________
Are you an owner of a unit located within the Fullerton Fountains Condominium?
1)
a.
Yes (Provide your Building Number and Unit Number.)
Building No. _______________
b.
Unit No. _______________
No (Stop. Please forward this survey to the owner of the unit as soon as possible.)
Do you reside in the unit?
2)
a.
Yes (Complete Part II for yourself and anyone else living in the unit.)
b.
No (Complete Part II for all residents in the unit.)
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Fullerton Fountains HOA Age Verification Survey
Part II: Identification of Unit Residents
Provide complete information for each resident in your unit including yourself, if applicable. All
information must be complete and age verification documentation for each resident must be
included or your submission will be considered incomplete and will be returned to you. If you
miss the submission deadline, you will be subject to fines and penalties.
Age exemption options for a resident less than 55 years of age include a person who:
A. was residing with the senior citizen prior to the death, hospitalization, or other prolonged
absence of, or the dissolution of marriage with, the senior citizen and was 45 years of age or
older, or was a spouse, cohabitant, or person providing primary physical or economic support
to the qualifying senior citizen.
B. is a disabled person or person with a disabling illness or injury who is a child or grandchild of
the senior citizen who needs to live with the senior citizen because of the disabling condition,
illness, or injury.
For each resident identified below, submit a clear copy of any one of the following: driver’s
license, birth certificate, passport, immigration card, military identification, or any other
state, local, national, or international official documents containing a birth date of
comparable reliability.
Resident 1 (for residents under age 55 enter exemption A or B from options (see above)
1)
a.
Full Name: ________________________________________________________________
b.
Age: __________ Date of Birth: (MM/DD/YYYY) ______ / ______ / ____________
c.
Relationship to Survey Respondent: ____________________________________________
d.
Submit a clear copy of any acceptable verification of age document (see above).
Resident 2 (for residents under age 55 enter exemption A or B from options (see above)
2)
a.
Full Name: ________________________________________________________________
b.
Age: __________ Date of Birth: (MM/DD/YYYY) ______ / ______ / ____________
c.
Relationship to Survey Respondent: ___________________________________________
d.
Submit a clear copy of any acceptable verification of age document (see above).
Resident 3 (for residents under age 55 enter exemption A or B from options (see above)
3)
a.
Full Name: ________________________________________________________________
b.
Age: __________ Date of Birth: (MM/DD/YYYY) ______ / ______ / ____________
c.
Relationship to Survey Respondent: ___________________________________________
d.
Submit a clear copy of any acceptable verification of age document (see above).
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