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CITY or
Submit by E-mail
35 North 1s' East
Rexburg, ID 83440
Affidavit of Legal Interest
State of Idaho
County of Madison
13'�M
Name
City
City of Rexburg
Phone: 208.359.3020
www.rexburg.org Fax. • 208.359.3022
Being first duly sworn upon oath, depose and say:
Address
State
(If Applicant is also Owner of Record, skip to B)
REXBURG
America's Family Community
A. That I am the rec owner of the property described on the attached, and I grant my
permission to: q y 4-0/f Gtic�o•L..,Q� --
Name „r _ L _ sAddress
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 _ day of 20 z�
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Id'io
Residing at: (7
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My commission expires: "7 3 7