CENTERLINE MONUMENTATION AFFIDAVIT
I, Error! Reference source not found., Error! Reference source not found., being first duly sworn, do
hereby say that in accordance with O.R.S. 92.070, I have correctly surveyed and marked with proper
monuments, the centerline corner as indicated on the original plat of SUBDIVISION NAME as recorded in
Volume , Page , Book of Town Plats for Polk County, Oregon.
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STATE OF OREGON
)
ss.
)
)
County of
This instrument was acknowledged before me on
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, 20
, by
Notary Public—State of Oregon
My commission expires:
CITY SURVEYOR APPROVAL
Approved this
day of
, 20
, in accordance with O.R.S. 92.070(4).
Salem City Surveyor
By
COUNTY SURVEYOR APPROVAL
Approved this
day of
, 20
, in accordance with O.R.S. 92.070(4).
Polk County Surveyor
By
\\ALLCITY\COMMON\TEMPLATE\PUBLICWORKS\VALL\_REAL PROPERTY\CENTERLINE MONUMENT AFFIDAVIT POLK_F.DOTX
After recording, return to:
Polk County Surveyor’s Office
820 Southwest Ash Street
Dallas OR 97338