AFFIDAVIT FOR INSERTION OF INITIALS ON PROPERTY DUPLICATE AND TAX LISTS State of Ohio County of Geauga ) : SS. ) being first (Address) , of (Name) duly cautioned and sworn, attests that he/she is a: Peace Officer Parole Officer Prosecuting Attorney Assistant Prosecuting Attorney Correctional Employee Youth Services Employee Firefighter EMT Other and as such requests that the property ownership of the following described property can be changed on the general tax list of real and public property and the general duplicate of real and public utility property from the current name to the initials as provided for in ORC 319.28(B)(1) enacted by HB 46 of the 127th Ohio General Assembly. The property affected by this affidavit is described as follows: Further Affiant Sayeth naught. (Name of Affiant) Sworn to before me and subscribed in my presence this day of Notary Public, State of Ohio This instrument prepared by: Filing of the affidavit is NOT subject to the conveyance fee pursuant to ORC 319.54 (G)(3)(c). American LegalNet, Inc. www.FormsWorkFlow.com