Reset Form

         HOMESTEAD DATABASE / ASSESSOR-EDIT LOGIN REQUEST 
         State Form 55801 (3-15) 
         Prescribed by the Department of Local Government Finance 
         
                                 LOGIN REQUEST SECTION 
Office Holder Name: _____________________________ E-Mail: _______________________________ 
Office: ______________________________________________________________________________ 
Telephone: _________________________________ Fax: _____________________________________ 
Signature of Office Holder: ________________________________ Date (month, day, year): ____________ 
 
                                 USER INFORMATION SECTION 
         PLEASE PRINT CLEARLY ALL INFORMATION EXCEPT SIGNATURE. 
                                  
User Name: ________________________________________ E-Mail: ___________________________ 
Department: _________________________________________________________________________ 
Address (number and street): ____________________________________________________________ 
City, State, and ZIP:____________________________________________________________________ 
Telephone: _________________________________ Fax: _____________________________________ 
Application(s) for which Login is Requested: ________________________________________________ 
 
By signing below, I acknowledge that I may not disclose information about computer passwords 
and identification characters. The login provided by my County Administrator is designated for 
my use when accessing online DLGF applications and I am responsible for all activity under my 
login. If I become aware of any breach or suspected breach of information security, I will promptly 
report it to my supervisor and the County Administrator. The County Administrator should in turn 
report the matter to the DLGF. In addition, I acknowledge my responsibility to secure all records 
that may contain confidential information from the view of or access by unauthorized persons. 
Confidential paper files should be stored in locked cabinets or drawers whenever feasible, should 
not be left unattended in areas where visitors may enter, and should be disposed of by shredding 
or other secure method. I understand that I may not allow access to electronic files by 
unauthorized persons, nor to authorized persons for unauthorized purposes, and that I must 
follow the electronic security measures for confidential and sensitive information that are 
established by my supervisor. 
 
Signature of User: ___________________________________ Date (month, day, year): ______________ 
 
County Administrator Use ONLY 
 
USERID: ________________ Completed By: __________ Date Completed (month, day, year): __________ 
 
APPROPRIATE ACCESS PROVIDED: ___________________________________________________