Free 49243.FH11 - Indiana

INDIANA DEPARTMENT OF NATURAL RESOURCES NOTIFICATION OF EJECTION FROM DNR PROPERTY
State Form 49243 (R / 5-08)

Property code

Case number

Reset Form
Name of property Date of occurrence (month, day, year) Time of occurrence AM PM

PERSON EJECTED
Name of person ejected Address (number and street, city, state and ZIP code) Sex Vehicle involved? Race Make Height Year Weight Hair Color Eyes Date of birth SSN/OLN (optional) License state and year Telephone number ( )

License/registration number

REASON FOR EJECTION
Property rule or statute regulation violated

312 IAC _________ - ________ - ________: IC ________ - ________ - ________ - ________
Brief description

DURATION OF EJECTION
Beginning date (month, day, year) Beginning time AM PM Ending date (month, day, year) Ending time AM PM

RESPONSIBLE DNR EMPLOYEE
Name of employee Signature of employee Employee position Date (month, day, year) Name of DNR division

NOTICE OF RIGHT TO ADMINISTRATIVE REVIEW This document constitutes the implementation of a corrective action against you by the Department of Natural Resources pursuant to IC 14-10-2-4; IC 14-11-2-1; 312 IAC 8-5-3. A property manager or another authorized representative may require a person to leave a DNR property or may otherwise restrict a person's use of a DNR property. Any fees paid are non-refundable pursuant to this action. If you have been ejected from a departmental property, you may appeal the corrective action by applying for administrative review. In order to obtain a review, a written petition containing the specific reasons for the appeal must be filed with the Division of Hearings within eighteen (18) days of receipt of the Notification of Ejection. The petition should be addressed to: Director of the Division of Hearings Natural Resources Commission 100 N Senate Avenue Room N501 Indianapolis, IN 46204
DISTRIBUTION: White - Property Office; Canary - Person Ejected; Pink - Division Headquarters; Goldenrod - LED Regional Office

VIOLATION OF THIS EJECTION NOTIFICATION MAY RESULT IN YOUR ARREST FOR CRIMINAL TRESPASS.