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OWNERSHIP AND PERMISSION FORM <br />ai \, <br />;j State Form 45937 (R5/4-12) <br /><.� INDIANA STATE HISTORICAL MARKER PROGRAM <br />'e16 INDIANA HISTORICAL BUREAU, STATE OF INDIANA <br />Topic of marker <br />Address of proposed site for marker (Provide exact address, GPS coordinates or detailed directions.) <br />05 <br />Owner of proposed site <br />i <br />Type of owner (Please circle: Federal, state, ocal{p�gover ut, private entity, or individual.) <br />Specify <br />Policies and Guidelines: ownership, installation, and maintenance of Indiana State Historical Markers <br />• The Indiana Library and Historical Board, upon the recommendation of the IHB, has the sole authority to authorize <br />installation, removal, and disposition of Indiana State Historical Markers. <br />• Regardless of the source/s of funding, markers remain the property of the State of Indiana. <br />• Installation of an Indiana State Historical Marker is contingent upon the receipt of the completed form by IHB. <br />• Any Indiana State Historical Marker needing repairs must be reported to the IHB. <br />• Local site maintenance help for Indiana State Historical Markers is desirable, but is not required for approval of the <br />marker. <br />Statement of intent by owner or owner's authorized representative: Date <br />❑ I hereby grant permission to install on the property described above an Indiana State Historical Marker, as approved <br />by the Indiana Library and Historical Board. <br />❑ I affirm that I have the authority to give permission for the entity named above and below. <br />❑ An inspection of the marker site by state personnel, if necessary, will be allowed. <br />Printed Name %�1xj <br />Title, if relevant <br />Organization, if <br />Mailing address <br />e <br />E-mail Z StjL/ 4_y LC2_AtL)-Fi)U <br />Telephone <br />