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TOWN OF SUNDERLAND

Date___________________                                                 Case#_________________

List Parties of in Interest

Petitioner________________________________________________________________

                         Name                               Mailing Address                           Zip Code

Abutters:  1. _____________________________________________________________

                 2. _____________________________________________________________

                 3. _____________________________________________________________

                 4. _____________________________________________________________

                 5. _____________________________________________________________

                 6. _____________________________________________________________

                 7. _____________________________________________________________

                               Name                          Mailing Address                       Zip Code

Owners of Land Directly Opposite:

                  1. _____________________________________________________________

                  2. _____________________________________________________________

                  3. _____________________________________________________________

                               Name                          Mailing Address                      Zip Code

Owners of land Within 300 feet of the property line:

1. _________________________________  8._________________________________

2. _________________________________  9.__________________________________

3. _________________________________ 10.__________________________________

4. _________________________________ 11.__________________________________

5. _________________________________ 12.__________________________________

6. _________________________________ 13.__________________________________

7. _________________________________ 14. _________________________________

Planning Board of Abutting

Town:______________________________________________________________

                                   *************************************************

Certified by: ________________________________________________________

                             Name                            Title                       Board of Assessors

Date:_________________________