Assignment of Liability Form

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

Assignment Liability Form

Lessee Contact Information:

Assignee:	Phone Number:
Address:
City:	State:	Zip:

Non-Compliance Issue(s):

The following work shall be completed by :

See letter for other pertinent information regarding instructions, extensions & regulations.

I/We assume the responsibility of the above corrective actions related to the above described lease.

Name (Printed)

Signature

Date