File #_______

RIGHT OF ENTRY ON PRIVATE PROPERTY

GRANTED TO THE CITY OF SPRINGFIELD, MASSACHUSETTS
AND OTHER AUTHORIZED PARTIES
FOR TORNADO-RELATED DISASTER ASSISTANCE DEBRIS REMOVAL
Property address:_________________________________________________________
Owner:__________________________________________________________________
Copy of Deed:____________________________________________________________
GIS/Assessors Office Info:__________________________________________________
GPS location: Longitude:___________________ Latitude: _____________________
Age of structure/property: _________________________________________________
Historical:________________________________________________________________
Underground storage/Utilities marked/identified_______________________________
Pools/SPA/Basement:______________________________________________________
Environmental:___________________________________________________________
Insurance Company and Policy number:_______________________________________
1) The undersigned hereby certifies and warrants that (he/she/they) ( is/are) the owner(s) of the
property described in this document, and do hereby request aid in removing debris to prevent
further damage to (my/our) property and therefore give freely and without coercion, and
the undersigned unconditionally authorize(s) the City of Springfield, Massachusetts, its
officials, employees, contractors and subcontractors, successors and assigns, the United
States of America and its assigns, including but not limited to any Federal agency, its
employees, officials, contractors and subcontractors (collectively referred to as the
Authorized Parties), to have the right of access and to enter in and onto the property
located as identified above for the purpose of removing and clearing any or all tornado
generated debris and wreckage of whatever nature from the above described property.
2) I/we fully understand that this right of entry is not an obligation to perform debris and
wreckage clearance. The owner(s) agree(s) that the City and other Authorized Parties , and
their respective employees, officials, contractors and subcontractors,
and other
representatives, successors and assigns, shall in their sole discretion determine whether to
undertake, and if undertaken, to determine the extent and nature of the actions to be taken
to accomplish, the debris and wreckage removing and clearing activities.
3) It is the owners responsibility to mark locations on the property of any utility lines including
water, sewer, and natural gas, damaged by the tornado.
4) Additionally the undersigned property owner agrees to indemnify and hold harmless the City,
the United States, and any other Authorized Parties, for any damage or injury of any type
whatsoever to the above-described property or to persons or personal property and fixtures
situated thereon, and hereby releases, discharges, and waives any and all actions, either legal
or equitable, which the undersigned owner has, or ever might or may have in the future, by

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reason of any action taken by the City, the United States, and/or any of the Authorized
Parties, to accomplish debris and wreckage clearance activities.
The undersigned owner(s) warrant(s) that is (has/has not) receive(d) any compensation for
performance of the debris clearance activities from any other source including the U.S. Small
Business Administration, Natural Resources Conservation Service, private insurance,
individual and family grant program or any other public assistance program.
In the event the City or other Authorized Parties undertake to perform debris and wreckage
removal activities, and if the undersigned and/or any other owner of the property receive(s)
compensation from any source for debris and wreckage clearance and removal on the
property, the undersigned and any other property owner will report the same to the City and
to FEMA, and will be responsible to reimburse the cost of such debris and wreckage clearance
and removal activities from such insurance proceeds.
The undersigned represents and warrants that (he/she/they) (has/have) full legal power and
authority to execute and fully perform the obligations under this Right of Entry without the
need for any further action, or that (he/she/they) (is/are) the duly appointed agent(s) of the
owner, and that (he/she/they) (has/have) full power and authority to execute and fully
perform the obligations under this Right of Entry without the need for further action.
The undersigned is fully aware that an individual who fraudulently or willfully misstates any
fact in connection with this Right of Entry shall be subject to a fine as provided under 18 U.S.
C. sec. 1001, or imprisoned for not more than five years, or both.

For the considerations and purposes set forth herein, (I/we) hereby set (my/our) hands and seals on
this ________ day of __________________, 2011.

Signed:
_________________________________________
Property Owner or Authorized Agent
Print Name
Current Telephone Number: _______________
Current Address: _________________________
________________________________________

Signed:
_________________________________
Witness
Date signed: ______________

Signed:
_________________________________________
Property Owner or Authorized Agent
Print Name
Current Telephone Number: _______________
Current Address: _________________________
________________________________________

Signed:
_________________________________
Witness
Date signed: ______________