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2. 
3. PROPERTY VALUATION ADMINISTRATION
   Darlene M. Plummer, PVA
   
   
   PLEASE SUBMIT A SEPARATE FORM FOR EACH PROPERTY
4. 1840 Simon Kenton Way Suite 3300
   Covington, KY 41011-2999
   Phone: (859) 392-1750
   Fax: (859) 392-1770
6. Property IDentification Number (PIDN)
7. Today's Date
   Today's Date
9. Property Location*
11. Owner's Name*
13. Owner's Mailing Address*
15. City*
16. State*
    -- Select One --AAAEAKALAPARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPR
17. Zip Code*
19. Phone Number*
20. Email Address*
22. Printed name of party requesting mailing address change*
24. Relationship to property owner (i.e. self, attorney, POA, etc.)*
26. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) you are authorized to make such change on behalf of the owner, 2) your application will not be signed in the sense of a traditional paper document, 3) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 4) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature*
31. In Accordance with KRS 134.119 (8)
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field