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(10-08-2009) <br /> I HEREBY CERTIFY THAT THE FOREGOING REPRESENTATIONS AND ATTACHMENTS <br /> ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. <br /> 1. JE.F--� �� Cj . c� C'� S`T" g — 2.0q- <br /> (Printed Name) (Date) <br /> C �gnature) <br /> 2. .D ( C Y-1( - a©17 <br /> (Printed Name) 4 (Date) <br /> (Signature) <br /> 3. c_ F_. WE. ` CM-r-\ _ 8 —15 —ZO t 1 <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 over 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 />