HomeMy WebLinkAboutApplicationAFFIDAVIT
I the undersigned, to the best of my knowledge and belief, submit the above information as true and correct.
k Signature of
Applicant:
ni 1 l`I A
(Printed Name)
STATE OF INDIANA
SS:
Title:
Date: 7 Z 0 2-1
The undersigned, having been duly sworn upon oath says that the above information is true and correct and he
is informed and believes.
(Signature o utioner)
County of
--� tj Before me the undersigned, a Notary Public
(County in which notarization takes place)
�,riMM
otaiy Public's county of residence)
County, State of Indiana, personally appeared
and ack novvledge the execution of the foregoing
roperty Owner A�ttomcy, or Power of Attorney)
instrument this U ' day of 20 4
(day) (month) (year)
KRISTA ANN LAWYER ary Public --Signature
Notary Public
Stateof Indiana _ +�i L•+��'�%
Commision No. 659746 Notary .Public4kc.a.w�e Print
My Commission Expires
Octoer 26, 2022My commission expires:
Revised: 3!8/2021 Filename: ADL:e & AULS Amend 202i