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Docusign Envelope ID: 9199AF63-50A4-442C-AE7A-7B4C4273688F <br />STATE OF+ <br />COUNTY OF <br />OWNERSHIP AFFIDAVIT <br />FOR LIMITED LIABILITY COMPANY <br />Public Hearing No. <br />Before me, the undersigned authority, personally appeared <br />hereinafter the Affiant (s), who being first duly sworn by me, on oath, deposes and says: <br />1. Affiant is the manager, or managing member of the <br />Limited Liability Company with the following <br />address: <br />2. The Limited Liability Company owns or lease (circle one) the property, which is the <br />subject of the proposed hearing. <br />3. The subject property is legally described as: <br />4, Affiant is legally authorized to file this application for public hearing: <br />5. Affiant understands this affidavit is subject to the penalties of law for perjury and the <br />possibility of voiding of any zoning granted at public hearing. <br />6. Affiant understands that the matters attached to and made part of the application are <br />honest and true to the best of my knowledge and belief. I understand this application must <br />be complete and accurate before the application can be submitted and the hearing <br />advertized. <br />Witnesses: <br />Signature <br />Print Name <br />Signature <br />Print Name <br />Affiant's Signature <br />Print Name <br />Sworn to and subscribed before me on the day of , 20 , <br />Affiant is personally known to me or has produced as <br />Identification. <br />Notary (Stamp/Seal) <br />Commission Expires: <br />Page 10 of 23 <br />27 <br />