TOWNSHIP OF MUDDY CREEK
PO Box 239
Portersville, PA 16051
Office: 724-368-3438 Fax: 724-368-3432
ADDRESS REQUEST FORM
PRESENT MAILING ADDRESS: **Please print clearly**
Property Owner Name: ____________________________________________
Current Address: _________________________________________________
_________________________________________________Current Phone Number:____________________________________________
INFORMATION NEEDED FOR ADDRESS: **Please print clearly**
Tax Parcel #: 240 - _____ - _____
Adjacent Property Owners: __________________________________________
__________________________________________Name the road the driveway connects with: _____________________________
Closest intersecting road is: __________________________________________
______________________________ ________________
________________Property Owner SignatureDate
DateTOWNSHIP USE ONLY:
Date Received: ______________________
Property Address Assisgned:__________________________________
