J4 Release Statement and Waiver Form.doc

Property: ___________________________________________________________

City: __________________________________ State: _______________________

Resident/Head of Household Name: ______________________________________

Address (Bldg. & Unit No.): ____________________________________________

Lord & Dominion’s Tenant I.D. #: _______________________________________

Release Statement and

Waiver of Receipt of Section 8 Voucher and/or Relocation Benefits

We, the undersigned, choose to waive__ not waive__ our rights to be considered for the issuance of a Section 8 Voucher. Further, we do__ do not__ want to participate in the above property’s relocation program or receive any relocation benefits.

Based on the above decision(s) and the associated consequences and events, we hereby jointly and severally waive our rights to be considered for a voucher and/or relocation benefits, whichever is applicable, and forever release, discharge, acquit, hold harmless and forgive Lord and Dominion Investments & Management Services and the U.S. Department of Housing and Urban Development from any and all claims, damages, actions, suits, demands, agreements, liabilities, judgments and proceedings, both at law and in equity.

This release and waiver shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal representatives.

Signed this ________day of ___________________, ______ in the presence of:

Witness Resident (Head of Household)

Witness Resident