(Space reserved for Clerk) ____________________________________________________________________________ OWNERSHIP AFFIDAVIT FOR INDIVIDUAL STATE OF _____________________ Public Hearing No. ____________________ COUNTY OF ___________________ Before me, the undersigned authority, personally appeared ______________________, hereinafter the Affiant, who being duly sworn by me, on oath, deposes and says: 1. Affiant is the fee owner of the property, which is the subject of the proposed hearing. 2. The subject property is legally described as: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 3. Affiant understands this affidavit is subject to the penalties of law for perjury and the possibility of voiding of any zoning granted at public hearing. [f:\forms\Affidavit Ownership Individual.doc (11/6/03)] Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com (Space reserved for Clerk) ____________________________________________________________________________ Witnesses: ____________________________________ Signature ____________________________________ Print Name ____________________________________ Signature ____________________________________ Print Name ___________________________________ Affiant's signature ___________________________________ Print Name Sworn to and subscribed before me on the _____ day of ____________________, ________. Affiant is personally known to me or has produced ___________________________________ as identification. __________________________________ Notary Public Signature ___________________________________ Print Name State of _______________________________ My Commission Expires: _____________________ [f:\forms\Affidavit Ownership Individual.doc (11/6/03)] Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com