Owner(s) Declaration of Annexation without Sewer Service (Annexation) : I (We) certify: (i) that I (we) have requested the Town to provide water to the property(ies) depicted on this map; (ii) that I (we) submit a voluntary annexation petition to the Town for the property(ies) depicted on this map; and (iii) that I (we) acknowledge and agree that the Town will not provide, nor does it have an obligation to provide, sewer service to the property(ies) depicted herein inasmuch as the property is not within a reasonable proximity to the Town sewer lines or drainage basin for the property(ies), thereby making the provision of sewer services impractical. The terms and provisions of this certification are further memorialized in Declaration of Annexation without Sewer Services agreement recorded in Book ________, page __________, in the Office of the Wake County Register of Deeds, said Agreement being incorporated herein by reference. Said agreement and this certification shall be binding upon the undersigned owner(s), their heirs, successors or assigns.
_______________________________ _______________________________ _______________________________
State of North Carolina, County of _______________________________ I certify that this (these) person(s) personally appeared before me this day of: ______________________, 20 , each acknowledging to me that he and/or she voluntarily signed the foregoing document for the purpose stated herein and in the capacity indicated: _____________________________ SEAL
_____________________________ _____________________________ Notary Public My commission expires: ______________________, 20
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