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Certification StatementCertification Statement I hereby certify that _________________________________________ is the owner of the property located at _____________________________________________________ which is the subject of this application, and that I, ______________________________, in my capacity as ______________________________________, am authorized to sign this application on behalf of the owner. I understand that knowingly providing false information on this Application may result in any action taken heron being declared null and void. I further understand that pursuant to TCA 39-16-301 et seq., knowingly making a material false statement, or otherwise providing false information with the intent to mislead a public servant in the performance of his duty is punishable as a Class B misdemeanor. _________________________________________ ____________ Signature Date _________________________________________ Printed Name and Title Note: A Certification Statement must be submitted with an application form requiring the owner’s signature if the owner of the subject property is a corporation, limited liability company, partnership, association, trustee, etc., or if someone other than the owner signs the application. All Certification Statements must be notarized. _________________________________________ ____________ Notary Signature Date