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2. Please complete all fields of this form. Read all fields carefully.
4. Property Owner's Name*
5. List all addresses of properties in Dubuque for which this designation will be effective:*
7. Will this person be the Primary Contact for the property/ies?*

   1. No. This person/agency will be a secondary contact able to respond in case of emergency.
   2. Yes. This person/agency will handle all matters related to management/maintenance of the listed property(ies), including licensing & inspection fees.
8. Please apply this designated information to:*

   1. All of my licensed properties
   2. Only the listed property/ies
10. Is this the first person/agency you are assigning to this property, or is this person/agency replacing an existing Designated Agent?*

    1. This is the first person/agency designated.
    2. This person/agency is replacing an existing Designated Agent for this property.
11. If this person/agency is replacing someone else, please list the existing Designated Agent's name.
13. This Designated Agent information needs to be updated for the following Housing & community Development programs:

    Please select all that apply

    1. Rental Licensing & Inspections
    2. Vacant Building Licensing
    3. Assisted Housing (Section 8, HCV)

    1. Rehabilitation Programs
    2. Lead & Healthy Homes
    3. Bee Branch Healthy Homes
15. Note: Regardless of the designation of a primary agent, the City will still notify the property owner on record in cases of exterior nuisance violations as required by state law. All other license and inspection documentation will be mailed to the primary agent.
17. Read below carefully and enter your name to indicate consent.*
    This e-form serves as official notification that I, as the property owner of the above mentioned property(ies), do hereby designate the party listed below, as the "Designated Agent", empowered as the owners' representative in matters related to the City of Dubuque Property Maintenance Code and other requirements of Title 14, Chapter 1, Article J of the City of Dubuque Code of Ordinances and all other applicable codes.
21. Designated Agent Information
23. Agent's Name*
24. Business Name, if applicable
26. Address 1*
28. Address 2
30. City*
31. State*
32. Zip*
34. E-mail Address
35. Phone Number (Primary)*
36. Phone Number (Secondary)
38. By submitting this form, I verify that all information is true and accurate.
    Please contact the Housing & Community Development Department at (563)589-4231 or housing@cityofdubuque.org with questions or for more information.
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field