HomeMy WebLinkAboutApplication pg 3AFFIDAVIT
I the undersigned, to the best of my knowledge and belief, submit the above
information as true and correct.
Signature
Applicant: of n o Title: 1 oeu r
&A E Date: �Z Q
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State of Indiana, Nutalrp'C
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Before me the undersigned, a Notary Public for Th'1��1�' Couiii'j�;'
State of Indiana, personally appeared c.- S O x and acknowledged the
execution of the foregoing instrument this ay of L-) e 20 C
y Commission Expires: -a
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Revised: 12/17/2008 filename: ADLS ADLS AMEND.APP 2009 3