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EXHIBIT G <br />Description of Adjacent Owner and Adjacent Property <br />Adjacent Property <br />Owner(s) of Record: <br />Interest Owned <br />(circle one) <br />Street Address: <br />Tax Id. Number(s): <br />Recording No. of <br />Applicant's Deed: <br />Owner's Deed <br />Recording Date: <br />Fee Simple --- Life Estate --- Owner of a I/ Interest. <br />Doc. No <br />South Bend, Indiana <br />or Deed Book , Page <br />I am the owner of the property interest specified above. I have reviewed this Cross Access <br />Easement Agreement and am duly authorized to approve and execute it. <br />DATE: <br />ADJACENT OWNER <br />By: <br />Printe <br />Its: <br />STATE OF INDIANA, COUNTY OF ) SS: <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally <br />appeared , known to me to be the <br />Applicant specified above and acknowledged the execution of the foregoing Agreement. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on <br />the day of , 24_. <br />(SEAL) <br />Notary Public <br />Residing in , Indiana <br />