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PT Form 961 (Revised 9/23/96) Minnesota Department of Revenue <br /> <br />Application for Approval of a New USe of Tax-Forfeited Lands <br /> (Minnesota Statutes, Section 282.01, Subdivisions la through lc) <br /> In ~ ~ o ~,a County <br /> <br />Name of governmental xubdivision (applicant): <br />M~ih'ng address of applicator: ~ ~' ~ ~- ~ <br /> <br />SlaIe deed Iltllllbel': ~ %c~ '~ ~ <br /> <br />Date state deed issued: el <br /> (month) <br /> <br />(day) <br /> <br />(year) <br /> <br />Legt,l de.~'cription of properO, (il,chide the name of the city/town in which the property is located): <br /> <br />Describe thc intended public use lb,' which tile property was previously conveyed (be specific, including statute o? special law <br /> <br />Describe thc new public nsc for tile property that is being requested (be specific, including statute or special law refe,'ences, if <br /> <br />THIS INSTRI. JlvlENT WAS DRAFI'ED BY: <br /> <br />Name <br /> <br />Address <br /> <br />STATE OF MINNESOTA <br /> <br />County of <br /> <br />SS. <br /> <br /> being first duly sworn, deposes and says that he/she is the authorized <br />representative c)f the governmental st, bdivision (applipant) named hereim that he/she has read said application and knows the contents <br />the,'eof, and that thc matters stated therein are true and correct. <br /> <br /> Name Title <br /> Subscribed and sworn to before me this <br /> day of 20_ <br /> <br />Notary Public, <br /> <br />My commission expires <br /> <br />County. Minn. <br /> <br />Return alll)licaii,m t¢): MN l)elmrt,nent at' Revenne · Property Tax Division · Mail Station 3340 · Stl Paul, MN 55146-3340 <br /> <br /> <br />