HomeMy WebLinkAboutAFFIDAVIT - 22-00681 - Madison Health - Madison Memorial Hospital - SignAffidavit of Legal Interest
35 North 1" East
Rexburg, ID 83440
State of Idaho
County of Madison
www.rexburg.org
Being first duly sworn upon oath, depose and say:
City of Rexburg
Phone: 208.359.3020
Fax: 208.359.3022
Address
State
(If Applicant is also Owner of Record, skip to B)
CITY OF
REXBURG
/\111erin1 S Family Commumty
1\. That l am the record owner of the property described on the attached, and I grant my
permission to: _____________ _
Name J\<ldrc:ss
to submit the accompanying application pertaining to that property.
B.I agree to indemnify, defend and hold Rexburg City and its employees harmless from any
claim or liability resulting from any dispute as to the statements contained herein or as to the
ownership of the property which is the subject of the applicat ion.
day of __ l_>_r_"'-______ , 20-'2..._z.. __ _
Subsc ribed and sworn to before me the day and year first above written.
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Nornry Public of ldah<>
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.M�, commission expire s: --'-�""-'\k--,-'--+-\ _,·2.=-='::)=------�\ I
Residing at: 'i:"¥) �, .
Andrew Petersen