Appendix I

(City Seal)         CITY OF NEWARK
            DEPARTMENT OF PUBLIC SERVICE
            CITY BUILDING, 40 WEST MAIN STREET
            NEWARK, OHIO 43055 [phone]

AUDITOR'S TAX INFORMATION FORM FOR LOT SPLITS OR LOT COMBINATIONS

I, the undersigned                           as ( ) the owner, ( ) the owners representative do hereby ( ) authorize ( ) request the Licking County Auditor to ( ) Combine ( ) Split the following:

PARCEL OR LOT NUMBER           NAME OF ADDITION

TO BE FURNISHED BY APPLICANT: You MUST submit a tax map from the Licking County Administration Offices with your request for a lot split or combination.

Buildings on parcel(s) or lot(s)                      

Reason for requested change                      

Tax Mailing Address and Phone No.                   

            SIGNED                 
                  (Owner's Signature)

            DATE                    

ACTION BY NEWARK CITY PLANNING COMMISSION

   Approved

   Denied                          
                  Planning Director

   Other                         
                  Date

(Ord. 93-62. Passed 10-3-94.)