Mills Act – Historic District Contributor Application Form 4
5. Owner Statement
Provide name and signature of each owner. For any trust or corporate ownership, provide the full name of the entity and the name and role of each signatory (trustee, partner, etc.) .
I/we hereby declare under penalty of perjury that I /we am/are the owner(s) of the property involved in this request and that the foregoing statement and the information submitted h erewith are true and correct:
___________________________________________________________________________________ Printed Name
______________________________________ ______________________________________ Signature Date
___________________________________________________________________________________ Printed Name
______________________________________ ______________________________________ Signature Date
___________________________________________________________________________________ Printed Name
______________________________________ ______________________________________ Signature Date
Edward Silver
8/21/2022
Kerry Silver
8/21/2022