CUYAHOGA COUNTY FISCAL DEPARTMENT 2079 E. NINTH STREET Room 4-100 CLEVELAND, OHIO 44115 TELEPHONE (216) 443-7089 FAX (216) 698-2748 OHIO RELAY SERVICE (TTY) 1-800-750-0750 AFFIDAVIT FOR INSERTION OF INITIALS ON PROPERTY DUPLICATE AND TAX LIST I,__________________________________________ Of _______________________________________, Name Address _____________________________________, OH ____________ being duly cautioned and sworn, attests City Zip That he/she is or was a: [ ] Peace Officer [ ] Prosecuting Attorney [ ]Correctional Employee [ ] Firefighter [ ] Parole Officer [ ] Assistant Prosecuting Attorney [ ] Youth Services Employee [ ] EMT And as such hereby requests that the property ownership of the following described property be changed on the general tax list of real and public utility property and the tax duplicate of same from the current listed name of ________________________________________ to the initials of ______________ as provided for in ORC 319.28 (B)(1) as enacted by HB 46 of the 127th Ohio General Assembly. The property affected by this affidavit is described as follows: (must attach legal description) Permanent Parcel No. _______________________________ A.F.N. ___________________________________ Further Affiant Sayeth Naught STATE OF OHIO )SS. COUNTY OF CUYAHOGA ) ) ____________________________________ Affiant Sworn To Before Me and Subscribed By Me, at _______________________________, Ohio, this ________ day of _______________________ A.D., 20______ ____________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com