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12/6/2012 <br />;c90 /, •: <br />ti�iii <br />INDIAN RIVER COUNTY <br />SOLID WASTE DISPOSAL DISTRICT <br />1891 27" STREET, VERO BEACH, FLORIDA 32960-3365 <br />VACANCY CREDIT <br />AGENT AUTHORIZATION <br />Type or print all information clearly <br />1, , <br />(NAME OF PARCEL OWNER) (TITLE) <br />authorize <br />(NAME OF AGENT) (AGENT'S BUSINESS NAME) <br />to act on my behalf to request Vacancy Credit for the following parcel(s): <br />Parcel <br />Parcel <br />Parcel <br />Parcel <br />Parcel <br />Parcel <br />Parcel <br />Parcel <br />N umber <br />N umber: <br />N umber: <br />N umber: <br />N umber: <br />N umber: <br />N umber: <br />N umber: <br />Tax Year: <br />This Agent Authorization shall remain in effect for a period of 12 -months from the date <br />listed below. <br />(signature of parcel owner) (date) <br />STATE OF <br />COUNTY OF . The foregoing instrument was acknowledged before me this day of <br />before me, by <br />(month) (year) (parcel owner) <br />Personally Known ' or Produced Identification _ <br />Type of identification Produced: <br />(Notary signature) <br />(Print Name of Notary) <br />NOTARY PUBLIC, State of <br />My Commission expires: <br />• <br />2 of3 <br />FASWDDIVACANCY CREDITt2013 VACANCY CREDIT REQUEST FORM draft #6 of6.dac <br />(seal) <br />