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Contact Information

Date(Required)

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Address for-List Type of Structure on Property:(Required)

Example: house, modular, mobile home, doublewide, garage, pole bldg, RV, etc.

If you would like to receive your new address by email please provide your email below:

Property Information

Needed information regarding the property you are wanting the new address for:

Township:

Is property to be split?

Yes

Property Parcel Number (Tax ID):

Please use this # format: 62-##-##-###-###

Driveway Location (Street):

Distance from edge of your property line to driveway:

Please provide in feet (ft.)

Edge of Property:

East

West:

North:

South:

Additional Comments for Driveway Location:

New Construction

Existing Building

Cell Tower

Power Pole

Out Building

Extra Address (please explain)

Other

Untitled

Signature of Property Owner (By typing your name this will considered your Official Signature)

New House Number Assignment

THIS IS ONLY TO BE FILLED OUT BY OUR STAFF. DO NOT FILL OUT.

Number Issued:

Number

Direction

Street Name

Post Office:

State:

State

Address

ZIP / Postal Code

Approved By:

Date

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New House Number Assignment

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