Adjacent Landowner Occupant Affidavit
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Adjacent Landowner Occupant Affidavit Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Tags: Adjacent Landowner Occupant Affidavit, 51872, Indiana Statewide, Department Of Enviromental Management
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.
2.
I hold the position of _____________________________ for_______________________________
(permit applicant’s or facility’s name).
3.
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.
4.
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.
5.
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
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
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