Affidavit of Permanently Absent Household Member

QUEST ASSET MANAGEMENT, INC,

PROPERTY NAME

Property Address, City, State, ZIP

Phone (000) 000-0000 Fax (000) 000-0000

Affidavit Of Permanently Absent Household Member

Date: __________________

Unit #: __________________

I, ___________________________________ hereby certify that the information provided below is accurate and correct to the best of my knowledge.

_____________ My spouse and I operate separate households.

Initials

_____________ My spouse will not reside in the apartment home.

Initials

_____________ My spouse and I do not intend to file a joint tax return for the present or

Initials upcoming calendar years.

_____________ The separation is permanent.

Initials

______________________________________ _________________________

Signature of Applicant/Resident Date

______________________________________ _________________________

Signature of Applicant’s Spouse (if possible) Date

(State of ______________________) (County of ________________________)

I, the undersigned Notary Public in and for the aforesaid County and State, do hereby certify that on this day the foregoing instrument was produced to me in the aforesaid County and State and acknowledged and delivered before me.

Given under my hand and seat this __________ day of _____________________________, 20_______.

(Notary seal) Signed _______________________________

Notary Public, State of ____________________

My commission expires: ___________________

PENALTIES FOR MISUSE: Title 18, Section 1001 of the U. S. Code makes it a criminal offense to make willful false statements or misrepresentations to any department of agency of the U. S. Government.

Revised 9/1/03