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e10-os-20(w) <br /> I HEREBY CERTIFY/THAT THE F REGOING REPRESENTAT ONS,AND ATTACHMENTS <br /> ARE TRUE AND CO RFCT TO TPE BEST OF MY KNOWLEDIAE. <br /> Jack Henris i S � <br /> (PfintedName) ( ate) <br /> (Signature) <br /> 2. <br /> (Printed Name) f (Date) <br /> (Signature) <br /> 3. <br /> (Printed Name) (Date) <br /> (Signature) <br /> 4. <br /> (Printed Name) (Date) <br /> (Signature) <br /> NOTE: SIGNATURES OF ALL PROPERTY OWNERS,AND THE AUTHORIZED <br /> APPLICANT, REPRESENTATIVE AND/OR AGENT IS REQUIRED <br /> (use space oust as needed) <br /> OTHER INFORMATION <br /> (attach additional sheets as necessary) <br /> FEE RECEIPT(official use only) <br /> Received By: Date: <br /> Amount Received:$ Check#: Receipt#: <br /> Page 4 of 4 <br />