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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