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Thomas B. Quaw Square ▪ 91 E. Central ▪ Belgrade, MT 59714 Phone: (406) 388-3560 Annexation Petition Supplemental Information Form Applicant Contact Information: 1. Property Owner Name: Address: City: State: Zip: Phone: Email: 2. Preparer/Agent Name: Address: City: State: Zip: Phone: Email: ---PAGE BREAK--- Thomas B. Quaw Square ▪ 91 E. Central ▪ Belgrade, MT 59714 Phone: (406) 388-3560 Site Information: 3. Location (Legal): 4. Geocode 06 5. Area (Acres): 6. Zoned: Yes ☐ No ☐ a. If Yes, Zoning District: 7. Description of Existing Structures: Elements Checklist ☐Petition ☐Location Exhibit ☐Narrative Description of Plans for the Site If Site is NOT Zoned ☐ Zone Map Amendment Application (including all requirements) ☐ Certified List of Property Owners Within 300-feet of the Exterior Boundary of the Proposed Zone Change I (We*) hereby certify that the above information is true and correct to the best of my (our) knowledge. Applicant’s Printed Name Applicant’s Signature Date Property Owner’s Printed Name Property Owner’s Signature Date *If property has multiple owners, please inquire with Planning Department for required signature(s).