Upon completion of the “self-certification” below, late fees, penalties, and reinstatement fees will be suspended for your real estate lease account. This suspension arrangement shall last for a period of ninety (90) days from the date of Port Commission Resolution 2020-04 (March 31, 2020) unless otherwise terminated or extended by the Commission.

The authority provided in resolution 2020-04 does not grant any authorities to forgive lease or moorage payments, and does not forgive late fees or penalties previously assessed.

Which of the following qualifying events apply to you?*

1. I am a business that has been shut down due to a Government order related to COVID-19 pandemic.

2. I am a business that has been financially impacted due to loss of income caused by the COVID-19 pandemic.

Please briefly explain your impacts.*

Business Name*

Customer Name*

Business Address (e.g. 2104 Garfield Ave NW)*

Customer Account Number*

Email Address*

• I certify that the information I have provided is true, and I agree to comply with the terms of the arrangement that will be established on my account.
• I understand this agreement does not apply to previously accrued late fees or penalties.
• I understand that this self-certification has been provided as a relief measure and will be terminated ninety (90) days from March 31, 2020, unless otherwise terminated or extended by the Port Commission.

By checking this box and signing below, I agree to the above statements.*

I agree

Type full name to complete form.*