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1 the undersigned, to the best of my knowledge and belief, submit the above information as true and correct.
Signature of
Applicant: Ct/i 7--' r`t` Title: t )24 r
4 7 0 1 i Date: U I ao )1
(Print)
STATE OF INDIANA
SS:
County of Ma (i Before me the undersigned, gn a Notary Public
(County in which notarization takes place)
for VL1' (CC County, State of Indiana, personally appeared
(Notary Public's county of residence)
1/ r and acknowledge the execution n of the foregoing instrument this
(Property Owner, Attorney, or ower of Attorney)
.11 day of t 1 20 1
No /Pub V 4 ture
(SEAL)
AA w 13. 416. w AN .6 .I
BRANDY I GIRT No P blic -P ease Print
„,,f, Navy Pubilq eat Madero 46:-0‘ September 12, 2018 3 ����yyyy
My commission expires: g_ Il�
3
Revised: 12 /28 /2010 fiLnamc: ADLS ADLS AMEND 2011