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COUNTY OF HAWAII <br /> PLANNING COMMIS S ION <br /> GEOTHERMAL ASSET FUND CLAIMS FORM <br /> CLAIMANT: <br /> CLAIMANT'S SIGNATURE: DATE: <br /> ADDRESS: <br /> TELEP HONE NO. (BUSINESS) (RESIDENCE) <br /> TAX MAP KEY: <br /> NATURE OF CLAIM: <br /> THIS PETITION MUST BE NOTARIZED AND ACCOMPANIED BY: <br /> 1. List of documents supporting the claim, showing evidence of adverse impact. <br /> 2. Additional information regarding the nature of the claim, including the way in which the <br /> claimant has been adversely impacted and the compensation sought. <br /> 3. When the claimant is an organization, the claimant shall submit a list of officers, a <br /> membership fist, and a copy of the organization's by-laws. <br /> 4. Original and fifteen (15) copies of the claim and all supporting documents. <br /> Subscribed and sworn to before me <br /> this day of <br /> Notary Public, State of Hawaii <br /> My commission expires: <br /> PD: 10/95 <br />