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Tax Map Key of Property: <br />GEOTHERMAL RELOCATION PROGRAM <br />CERTIFICATION OF PROPERTY OWNER <br />Date <br />I CERTIFY, SWEAR AND AFFIRM THAT: <br />I am the owner of the above referenced property; <br />The above referenced property is within a one (1) mile radius of the Puna <br />Geothermal Venture facility; <br />I purchased the above referenced property before October 3, 1989 or <br />Received a building permit for the dwelling unit before that date and final <br />inspection for the dwelling unit has been completed by the Department <br />of Public Works, Building Division; <br />I occupied the above referenced property as my primary residences as of <br />October 3, 1989 or immediately occupied the property as my primary <br />residence upon completion of the dwelling if completed after that date; <br />The above referenced property and its improvements conform with <br />applicable State and County laws, codes, ordinances, rules and <br />regulations; and <br />I wish to relocate and sell my property to the County of Hawaii under the <br />Geothermal relocation program. <br />I understand that in the event that fans are initially insufficient to purchase all of the <br />dwellings and properties, those located closest to the Puna Geothermal Venture facility <br />shall be negotiated first. <br />Signature <br />Mailing Address <br />Telephone Number <br />STATE OF <br />COUNTY OF <br />Print Name <br />1, undersigned, a Notary Public in and for said State of Hawaii, hereby <br />certify that I is signed to the foregoing <br />certification, and who is known to me, swore and acknowledged before me on <br />this day that, being informed of contents and the penalties of perjury, he/she <br />swore to and executed the same voluntarily on the day the same bears date. <br />GIVEN under my hand and official seal of office, this -day of <br />100 . <br />Notary Public <br />My Commission Expires:_ <br />