Adjacent Landowner Occupant Affidavit {51872}

ADJACENT LANDOWNER/OCCUPANT AFFIDAVIT State Form 51872 (8-04) Indiana Department of Environmental Management ___________________________________________, being first duly sworn upon oath, deposes and says: 1. 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 ) 2. 3. 4. 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 American LegalNet, Inc. www.FormsWorkflow.com