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2. Date of Request
   Date of Request
3. Requestor Email Address

   Please provide preferred contact email

5. Name of Requestor
6. Requestor Phone Number
8. Current Owner
9. Previous Owner

   Only needed if recently purchased

11. Parcel #

    (ex: 10200-00305-090-26)

12. Plat Doc #

    (Ex. 2021-0519)

13. Legal Description
15. Approximate location of structure and location/description of driveway access
16. Road District Name (if applicable)
17. Road District Approval*

    1. I agree

    I agree to obtain approval from my road district for the proposed drive way access as shown in the address request form

18. Type of Structure
    -- Select One --New Build - no structures on lot yetExisting StructureCabinOther
20. Upload Copy of Your Deed
21. Upload Site Plan

    The site plan needs to include the exact location of your approach/driveway off the access road. Addresses are issued based up your approach location, not necessarily your home site.

23. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
25. Electronic Signature
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field