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35 North 1 st East
Rexburg, ID 83440
Affidavit of Legal Interest
City of Rexburg
Phone: 208.359.3020
www.rexburg.org Fax: 208.359.3022
State of Idaho
County of Madison Name Address
S!-�(:�22,
City State
CITY OF
REXBURG
America's Family 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 grapt my,
permission to: c t .` - i l c� f P z (� I'�/ tP 11 �S l v y G L&�,,ti, t, ! S A {L v '�' ,
Name Address(cI+'-'t C>, �(� 3 2
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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 5'�`^ day of At ,nL , 20a,r%
Signature
Subscribed and sworn to before me the day and year first above written.
`.30
Notary Public of Idaho
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