her/its knowledge. Print Name of Owner: Signature: Date (mm/dd/yyyy) I2. 23-. I I Name and Title of Person Signing for Owners lf applicable: _JEFFey E. Epsreisi, Thss • BCS-7CRF-ACRiS REV. 8/08 2 2011122700132101 EFTA00030134 --- PAGE BREAK --- FOR CITY USE. ONLY C 1 . County Code 1 L 1 C2. Date Dee