Free 52086.pdf - Indiana

ADJACENT PROPERTY OWNERS LISTING -- Form N4
State Form 52086 (3-05)

Approved by the State Board of Accounts, 2005

Mail To: Department of Natural Resources Division of Water 402 West Washington Street, Room W264 Indianapolis, Indiana 46204-2641 Telephone Number: (317) 232-4160 Toll Free: 1-877-928-3755 Fax Number: (317) 233-4579 www.IN.gov/dnr/water

4.

PUBLIC NOTICE IN CONFORMANCE WITH IC 14-11-4 AND 312 IAC 2-3-3
Personal service was provided on: (date)

Property Owner (if not applicant or adjacent landowner)

Address

1st Class Mail service was provided on: (date). I affirm that 21 days have passed without the mailing returned as undelivered or undeliverable. Attached is PS Form 3817 as proof of mailing. Certified Mail service was provided on: (date). Attached is PS Form 3811 (green card) as proof of mailing. Personal service was provided on: (date)

City

State

ZIP Code

Adjacent Property Owner

Address

1st Class Mail service was provided on: (date). I affirm that 21 days have passed without the mailing returned as undelivered or undeliverable. Attached is PS Form 3817 as proof of mailing. Certified Mail service was provided on: (date). Attached is PS Form 3811 (green card) as proof of mailing. Personal service was provided on: (date)

City

State

ZIP Code

Adjacent Property Owner

Address

1st Class Mail service was provided on: (date). I affirm that 21 days have passed without the mailing returned as undelivered or undeliverable. Attached is PS Form 3817 as proof of mailing. Certified Mail service was provided on: (date). Attached is PS Form 3811 (green card) as proof of mailing. Personal service was provided on: (date)

City

State

ZIP Code

Adjacent Property Owner

Address

1st Class Mail service was provided on: (date). I affirm that 21 days have passed without the mailing returned as undelivered or undeliverable. Attached is PS Form 3817 as proof of mailing. Certified Mail service was provided on: (date). Attached is PS Form 3811 (green card) as proof of mailing. Personal service was provided on: (date)

City

State

ZIP Code

Adjacent Property Owner

Address

1st Class Mail service was provided on: (date). I affirm that 21 days have passed without the mailing returned as undelivered or undeliverable. Attached is PS Form 3817 as proof of mailing. Certified Mail service was provided on: (date). Attached is PS Form 3811 (green card) as proof of mailing.

City

State

ZIP Code

I hereby swear or affirm, under the penalties of perjury, that the aforementioned statements submitted herewith are to the best of my knowledge and belief, true, accurate and complete, and that the property owner(s), and adjoining landowners have been notified of the activity in conformance with the provisions of 312 IAC 2-3-3.

Application Number

Signature

Date (month, day, year)