Form 49785 - Affidavit: Applicant Notification To Adjoining Property Owners/occupants - State Of Indiana
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2Affidavit: Applicant Notification to Adjoining Property Owners/Occupants
State Form 49785 (7-00)
Indiana Department of Environmental Management
To be completed by the Applicant:
___________________________________________________________ , being first duly sworn upon
oath, deposes and says:
1.
I live in ____________________ County, state of ___________________, 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 name), I am authorized to make the representation contained in the affidavit on
behalf of the facility.
4.
I understand that the notice requirement of IC 13-15-8 applies to ____________________________
_____________________________________________________________ (permit applicant’s or
facility’s name) for purposes of the accompanying permit application.
5.
As required by IC 13-15-8, the permit applicant will send written notice to adjoining landowners and/or
occupants not more than ten (10) days after the submission of the accompanying application for
_________________________________________________________________________________
_________________________________(briefly describe the type of permit application) filed on behalf
of __________________________________________________(permit applicant’s or facility’s name).
Further Affiant Saith Not.
I affirm under penalty for perjury that the representation contained in this affidavit are true, to
the best of my information and belief.
_____________________________________________
Signature of Affiant
______________________________
Date
_____________________________________________
Printed Name
To be completed by a Notary Public:
STATE OF ____________________
)
COUNTY OF ______________________ )
Before me a Notary Public in and for said County
and State, personally appeared ______________________________________, and being first sworn by me upon oath, says that the
facts stated in the foregoing instrument are true. Signed and sealed this ____ day of _________________, 20____.
Signed:
_____________________________________________________
My Commission Expires:_____________________
Printed:
Resident of
State
County
See page 2 (or reverse side) for additional information.
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