(Recorder’s Use)
State of / )
) ss.
County of / )
, being first duly sworn on oath, states that he/she holds the
greatest percentage of beneficial interest in the parcel of land known by it
County Property Identification Number(s) / ; that he/she has knowledge of the
facts herein; and that the holders of beneficial interests in the parcel, their addresses, the descriptions of
their interest and their percentages of the whole interests are as follows:
Please select either {1} list of interest holders (additional lines for interest holder information may be added, if necessary) or {2} Publicly traded stock statement. Delete the inappropriate choice.
Name and Address / Description of Interest (e.g., trust beneficiary, general partner, limited partner, corporate shareholder, heir) / Percentage of Interest
1.
2.
OR
That the interest, stock, or shares of the owning entity are publicly traded and there is no readily known
individual having a greater than 7½ percent interest in such entity.
Further affiant sayeth not.
Printed 3/1/10Page 1 of 2AER 2465 (Rev. 03/01/10)
VERIFICATIONUnder penalties of perjury, I certify that the name(s), address(es), descriptions and percentages of interest, and taxpayer identification number(s) listed above or information that the owner is a corporation
whose shares are publicly traded, is/are correct.
State of / )
) ss.
County of / )
I / , a Notary Public, in and for said County and State aforesaid, do
hereby certify that / who is personally known to me to be
the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he/she signed, sealed and delivered the said instrument as his/her free and voluntary act, for the uses and purposes therein set forth.
Given under my hand and notarial seal this / day of / , A.D. / .
(SEAL)
Notary Public
My commission expires / .
The original signed copy of this form must be submitted to the Illinois Department of Transportation, Division of Aeronautics, 1 Langhorne Bond Drive, Springfield, IL 62707-8415, Attn: Land Acquisition. To expedite processing this completed signed form may be scanned and emailed to or faxed to 217/785-4533.
Printed 3/1/10Page 1 of 2AER 2465 (Rev. 03/01/10)