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OGDEN CITY BUSINESS LICENSING 2549 WASHINGTON BLVD, STE 240 OGDEN, UT 84401 GOOD LANDLORD INCENTIVE PROGRAM WAIVER APPLICATION Applicant’s full name: Applicant’s date of birth: Applicant’s contact telephone number: Name of agency referred by: Parole officer/case worker name: Parole officer or agency phone number: I understand that a waiver shall be valid for one year. I understand that I am required to renew a waiver on an annual basis. I agree to provide Ogden City business licensing with a BCI report (current to within thirty 30 days) upon renewal. I understand I must present a copy of this application to a prospective landlord and the landlord or landlord’s agent must contact Ogden City business licensing, at 801- 629-8687, to confirm that a waiver has been granted. REVOCATION: I understand that a waiver may be revoked under the following circumstances: Waiver tenant fails to renew the waiver annually; Waiver tenant fails to present a current BCI report to Ogden City business licensing every twelve (12) months; Waiver tenant is convicted of a crime listed in subsection 1745-4.A.3 of the Ogden Good Landlord policy; Waiver tenant obtains a disqualifying RIM level. APPEAL: I understand I may appeal the denial or revocation of a waiver to a hearing officer by filing a written appeal with the office of the city recorder within thirty (30) days of the denial or revocation and shall include the required twenty five dollar ($25.00) filing fee. I shall have the burden of proving that the waiver should be granted or otherwise not revoked. Application is APPROVED when initialed, dated and embossed in the box to the right Approved by: Dated: ---PAGE BREAK--- AUTHORIZATION TO RELEASE INFORMATION: I, certify that the above information is true and correct as of the date of this application, and agree that the Ogden City Police Department is authorized to contact my parole officer and that AP&P is authorized to release my RIM level, or equivalent, and other private information to the Ogden City Police Department, if requested. Applicant Signature: Date: Landlord Signature: Date: APPLICANT SHALL RETAIN A COPY OF THIS RECORD TO PRESENT TO PROSPECTIVE LORDLORD Landlord Requirements Landlords’ participation in the Good Landlord Waiver Pilot Program is completely voluntary; no landlord shall be required to participate. Prior to entering into a lease agreement with an applicant presenting an approved waiver form the Landlord shall contact Business Licensing at [PHONE REDACTED] to confirm validity of waiver form Upon confirming validity of waiver form the Landlord shall provide Business Licensing the rental property address including unit number if applicable and whether any other tenants with waivers are presently residing on the property. If a waiver form is found to be invalid Landlord shall not enter into a lease agreement with applicant. Landlord may be subject to dismissal from the Good Landlord Program for failure to comply with waiver program policies and procedures. THIS RECORD IS CLASSIFIED AS PRIVATE PURSUANT TO UTAH CODE ANN. SECTION 63G-2-302. ---PAGE BREAK---