GEOTHERMAL RELOCATION PROGRAM FORM (2)

Home

GEOTHERMAL RELOCATION PROGRAM CERTIFICATION OF PROPERTY OWNER Tax Map Key Number:____________________________________ Date:______________________ I CERTIFY, SWEAR AND AFFIRM THAT: I am the owner of the above referenced property; The above referenced property is within a one (1) mile radius of the Puna Geothermal Venture facility; The dwelling is a permitted structure and has been inspected and finalized by the County of Hawai‘i Department of Public Works, Building Division; I occupy the above referenced property as my primary residence; The above referenced property its improvements conform with applicable State and County laws, codes, ordinances, rules and regulations; and I wish to relocate and sell my property to the County of Hawai‘i under the Geothermal Relocation Program. I understand that in the event that funds are initially insufficient to purchase all of the dwellings and properties, those purchased before October 3, 1989 followed by those located closest to the Puna Geothermal Venture facility shall be negotiated first. ____________________________________ _______________________________________ Signature Print Name ____________________________________ Mailing Address _____________________________________ _______________________________________ Telephone Number Email address STATE OF HAWAI‘I__________) ) SS. COUNTY OF HAWAI‘I________) I, undersigned, a Notary Public in and for said State of Hawai‘i, hereby certify that ____________________, is signed to the foregoing certification, and who is known to me, swore and acknowledged before me on this day that, being informed of contents and the penalties of perjury, he/she swore to and executed the same voluntarily on the day the same bears date. GIVEN under my hand and official seal of office, this _______ day of _________________20___. _____________________________________ Notary Public My Commission Expires: _________________