Rural Address Request by Z9s2NXTJ

VIEWS: 1 PAGES: 1

									              CARBON COUNTY MONTANA - DISASTER & EMERGENCY SERVICES
              Rural Address Request Form                       $100 Processing Fee


                                  ☐ New Construction          ☐ Re-assign Address

Date: Date_______

First Name: First Name__________                       Last Name: Last Name_____________

Additional Occupants in Household: List additional occupents___________________________

Current Mailing Address: Mailing Address___________________________

City: City____________         State: State____        Zip: Zip__________

Property Phone: Phone______ Cellular Phone: Cell Phone _____ Other Phone: Other Phone_____

Preferred Road Name: Road Name__________________________

Do you ☐ own or ☐ rent the property?

Additional comments concerning address assignment: Additional Comments__________________
__________________________________________________________________________________
__________________________________________________________________________________


Send address notification by ☐ mail or ☐ email         Email Address: Email____________

Please return completed form to Carbon County DES, PO Box 887 / 17 West 11th St., Red Lodge, MT 59068
Questions? 406.446.1038 or DES@co.carbon.mt.us


  For Office Use Only                Fee Collected ☐ Yes ☐ No           Check No.: ______________

  GPS Coordinates
  Approach Origin:         Waypoint #: __________ Easting: __________ Northing: __________
  Residential structure:   Waypoint #: __________ Easting: __________ Northing: __________

  Location Map

								
To top