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Please send a property status report for property owned by___________________________
located on__________________________________ Road
Tax Assessment Map____, Grid/Block____, Parcel____ Lot____(if applicable),
Name of Subdivision (if applicable):______________________________.
Applicant's Day Phone Number:_______________________
Send report to:
Name:______________________________________________
Mailing Address:______________________________________
City/State/Zip:________________________________________
Fax report to:________________________(put n/a if you do not want us to fax this report)
I understand this report may take a minimum of 30 days processing time
Owner's Signature:___________________________ Date:_______________
A SEPARATE REPORT IS REQUIRED FOR EACH PARCEL.
-------------------------Health Department Use Only below this line----------------------------
Date Rec’d:__________ Receipt #______________ TN#________