Owner Information Sheet for Hold Harmless Agreement for
Encroachment Into Board's Easement

Mandatory fields marked with an asterisk (*)

Form Completer Information

• *Email Address of Person Completing This Form:
   
• *Name of person completing this form:
• *Affiliation (company) of person completing this form:

Project Owner

• Complete legal name, mailing address and phone number of PROJECT OWNER (including name of person to contact if a company):
• *First Name (Required) and Middle Initial (Optional):
• *Last Name:
• *Address:
  
  
• *State and Zip Code:
  Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Phone Number:

Lessees

• Complete legal name, mailing address and phone number of any LESSEES on property (including name of person to contact about agreement if company):
  
  (Please click "Update List" after adding/removing LESSEES in order to submit a correct list.)
• Lessee:
• First Name and Middle Initial:
• Last Name:
• Address:
  
  
• State and Zip Code:
  Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Phone Number:

Project

• *Describe the nature of the project and the encroachment into the Board's easement:
• *Attach drawing of encroachment suitable for recording in Montgomery County
  real property record.