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35 North 151 East
Rexburg, ID 83440
Affidavit of legal Interest
State of Idaho
County of Madison
City of Rexburg
Phone: 208.359.3020
www.rexburg.org Fax: 208.359.3022
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Name
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City
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Address
State
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CITY O F
REXBURG
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America's bimify Community
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described on the attached, and I brant m Q,
permission to: I YDYJ iCA.� �1 bD+�ii£ CAPAL l�J S. 2� Vy' ebur � �?`i90
Name Address
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 application.
Dated this I day ofT4toAyo 20_
Subscribed and sworn to before me the day and year first above written.
VICKI WEEKES Ira
Notary Public
State of Idaho Notary Public of Idaho
Commission #65053 �/Iw �x
Expires - 03/08/2027 Residing at: ' y I 2 1 -1 GLGU'l
My commission expires: 3I I ZUZ�