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a f,• aG` 1 <br />City of South Bend, Indiana <br />Reasonable Accommodations Attachment # 1— page 2 of 5 <br />APPLICATION FORM TO REQUEST A REASONABLE ACCOMMODATION <br />1. Name and Contact Information of Owner of Property: <br />Name: <br />Street Address: <br />City, IN Zip Code: <br />Telephone: Landline: Cell: <br />2. Tax Identification Number: <br />3. Is there a contingent purchaser? des _no. If answered yes, complete the following: <br />Name of contingent purchaser: <br />Street Address <br />City, IN Zip Code: <br />Telephone: Landline: Cell: <br />4. If the person requesting a reasonable accommodation is making such request on behalf of an entity <br />other than a natural person, the following information is required: <br />Name of entity registered with the Indiana Secretary of State: <br />Agent of record with Indiana Secretary of State: <br />Address: <br />Telephone: Landline: Cell: <br />Employer Identification Number: <br />South Bend City License/Permit Number: <br />12 <br />