APPLICATION FOR CERTIFICATE
REGARDING PUBLIC TRUST BOUNDARY

SECRETARY OF STATE
Public Trust Tidelands Office	No.___________
Public Lands Division
Post Office Box 97	Date Received______________
Gulfport  MS  39502-0097
(601) 864-0254

1.	OWNER IS:

	________ Individual   ________ Partnership   ________ Corporation   ________ Public Agency

	Applicant's Name 									

	Address 										

	Telephone (      ) _________________    (      ) _________________
                                                   Business                               Other

	If there is more than one owner of record, please provide the information requested above for all such owners on a separate sheet of paper.

2.	GEOGRAPHIC LOCATION OF PROPERTY: 

	Section _________  Township _________ Range __________ County 			

	Nearest City/Community 								

	Name of Waterbody (if any) 								

3.	RECORDATION OF DEED:

This Deed is found in the Record of Deeds of the Chancery Clerk of _________________ County, District _____, at Book ______, Pages ______

4.	LOCATION OF PROPERTY:

	Subdivision, Block, and Lot No. 								

5.	TAX ASSESSOR'S PARCEL NO. 							
6.	LEGAL DESCRIPTION OF PROPERTY:  (Please attach a copy of a survey of the property, if available.)

												

												

7.	SIGNATURE AND CERTIFICATION:

	All statements contained above are true and correct to the best of my knowledge and belief.  I agree to provide any additional data or information which may be required or requested by the Office of the Secretary of State.

	_______________________________________________   	________________
	Signature of Applicant 						Date

   	_______________________________________________________
	Title (If Partnership, Corporation or Public Agency)