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CERTIFICATION OF TREASURER/COLLECTOR (MGL c.40,§57; WMC 3-24) Office Use Only: DEPARTMENT NOTE - ALL LINES MUST BE COMPLETED BY APPLICANT. 1. Parcel which directly relates to the application filed. (This numeric Parcel I.D. can be found: on the tax bill, or in Street Listing Records at the Building or Assessor's office. Web:.http://data.visionappraisal.com/WoburnMA/. (Example I.D.: 12-34-56) 2. Map ______________ Block ________________ Lot _______________ Does Real Estate owner and/or tenant own or have a beneficial or financial interest in any other real estate properties within the city of Woburn? Circle one: NO YES A beneficial interest can be as an individual, partnership, trust, LLP, LLC etc. If YES, insert Map, Block, and Lot below for each property. Use back of form, if necessary. Map ______________ Block _________________ Lot _______________ Map ______________ Block _________________ Lot _______________ 3. Property Address where permit is sought:_____________________________________________ Real Estate Owner Name(s): _________________________________________________________ Real Estate Owner(s) Legal Business Name (if any): ________________________________________ Real Estate Owner's Residential Address (if different):_______________________________________ Telephone Number:________________________________________________________________ Tenant/Lessee Name: ____________________________________________________________________________ Legal Business Name (if any):________________________________________________________ Tenant's Address: _______________________________Telephone Number: _________________ 4. Check one: Residential Individual/Sole Proprietor Corporation Trust LLC/LLP Other ____________________________________ 5. I certify under the penalties of perjury that I am the record owner or tenant of the within described property and the above information is accurate and complete. _________________ Date _________________ Title ________________________________________ Signature of Applicant Property Owner or Tenant (Not contractor) ________________________________________ Print Name (For Office Use Only) CERTIFICATION OF TREASURER/COLLECTOR The records of this office indicate that there are no unpaid real estate taxes, municipal fees, liens or other municipal charges outstanding and unpaid, or for the payment of which the owner has entered into a payment agreement with this office, on the above described parcels as of: ____________________________ Certification Date EXPIRES: ___________________ __________________________________ Treasurer/Collector * FAXES OR SIGNATURE COPIES WILL NOT BE ACCEPTED * For copies of this form: http://www.cityofwoburn.com/index.asp?nid=279 American LegalNet, Inc. www.FormsWorkFlow.com