All Fields Required

Owner’s Name

Grid Number

Physical Address of Parcel

Old Address

New Address

I agree to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are all correct and complete to the best of my knowledge. I also certify that I understand the questions and statements on this application. I understand the penalties for giving false information. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

First Name

Last Name

Email Address