Age Verification Updated 2022.04

Age Verification

Data and Valid ID Required Pursuant to Federal Housing For Older Persons Act.
Address*
Enter your Gallery street address.
Name of Qualifying Resident (55 years of age or older)*
Email of Qualifying Resident*
example@example.com
Date Qualifying Resident first resided in the home*

MonthDayYear
Qualifying Resident is:*

An OwnerA Tenant
Fill in the blank(s) with the name and age of other occupant(s):
First Name Last Name Age
CERTIFICATION AND SIGNATURE:

I will provide the Gallery Office with documentation of proof of age for the Qualifying Resident. I certify that the documentation is a true and correct copy of the original and that I am the Qualifying Resident for the above-referenced Lot/Unit, being at least 55 years of age. I declare under penalty of perjury under the laws of the State of California that the foregoing statements are true and correct.
Enter date this document is being executed*

MonthDayYear
Enter city & state at which this document is being executed*
Qualifying Resident Signature *

Clear
Use your mouse or touch screen to enter the signature of the Qualifying Resident
Enter Name of Qualifying Resident 55 years of age or older
REMINDER:

Please provide documentation of proof of age for the Qualifying resident. For example: Driver's License, Birth Certificate, Passport, Immigration Card Military Identification or any other state, local, national or official document containing a birth date of comparable reliability.

Place the document in a SEALED envelop and return it to the Gallery Office within 30 days of submitting this form.

This information will be maintained in the strictest confidence and will be used ony for statistical purposes and to satisfy governmental requirements. Thank you for your assistance and anticipated cooperation.
Current Age of Qualifying Resident*
ex: 58
First Name Last Name Age
Should be Empty: