250 Broadway, 29th Floor New York, NY 10007 212-386-0009 - Phone 646-500-6271 - Fax www.nyc.gov/bsa AFFIDAVIT OF OWNERSHIP AND AUTHORIZATION Affidavit of Ownership ________________________________________, being duly sworn, deposes and says that (s)he resides at___________________ , in the City of _________________, in the County of ______________, in the State of _____________________ ; that ______________________ is the owner in fee of all that certain lot, piece or parcel of land located in the Borough of ___________________, in the City of New York and known and designated as Block __________, Lot(s) _______________, Street and House Number ___________________________; and that the statement of facts in the annexed application are true. Check one of the following conditions: __ __ __ __ Sole property owner of zoning lot Cooperative Building Condominium Building Zoning lot contains more than one tax lot and property owner Owner's Authorization The owner identified above hereby authorizes _______________________________________________ to make the annexed application in her/his behalf. Signature of Owner Print Name Print Title Sworn to before me this _________________ day Of _____________________ 2 ________________ _________________________________________ ________________________________ ________________________________ ________________________________ Revised March 8, 2012 American LegalNet, Inc. www.FormsWorkFlow.com