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Address Assignment Request

2. Requested By:
3. Date*
   Date
5. Email*
6. Phone Number*
8. Owner Name*
10. Property ID# (18 digit number with dashes)*
    (xx-xx-xx-xxxx-xxxx-xxxx)
12. Type of Structure (new or replaced)
14. Front of Structure/Street Name
    (for corner lots)
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field