Free 51872.pdf - Indiana


File Size: 49.0 kB
Pages: 1
Date: August 17, 2004
File Format: PDF
State: Indiana
Category: Government
Author: shuffman
Word Count: 256 Words, 2,170 Characters
Page Size: Letter (8 1/2" x 11")
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http://www.state.in.us/icpr/webfile/formsdiv/51872.pdf

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ADJACENT LANDOWNER/OCCUPANT AFFIDAVIT
State Form 51872 (8-04)

Indiana Department of Environmental Management

___________________________________________, being first duly sworn upon oath, deposes and says: 1. 2. 3. 4. I live in __________________ County, Indiana, and being of sound mind and over twenty-one (21) years of age, I am competent to give this affidavit. I hold the position of _____________________________ for_______________________________ (permit applicant's or facility's name). By virtue of my position with _______________________________________ (permit applicant's or facility's name), I am authorized to make the representation contained in this affidavit on behalf of the facility. I understand that the notice requirement of IC 13-15-8 and 329 IAC 10-12-1(a)-(b) applies to ____________________________________________ (permit applicant's or facility's name) for purposes of the accompanying permit application. As required by IC 13-15-8 and 329 IAC 10-12-1(a)-(b), the permit applicant will send written notice to adjacent landowners not more than ten (10) days after submission of the accompanying application for _______________________________________________________________________________ (briefly describe type of permit application) filed on behalf of ______________________________________________________________ (permit applicant's of facility's name). Further Affiant Saith Not. I affirm under penalty for perjury that the representations contained in this affidavit are true, to the best of my information and belief. __________________ Date ________________________________ Signature of Affiant ________________________________ Printed Name STATE OF COUNTY OF ) )SS )

5.

Before me a Notary Public in and for said County and State, personally appeared ____________, and being first duly sworn by me upon oath, says that the facts stated in the foregoing instrument are true. Signed and sealed this _________ day of _________, 20 ______. ______________________________________________________ Printed:________________________________________________ My Commission Expires:____________________ Residence of _______________ County