Application Number _______________________
CITY OF FALLS CHURCH, VIRGINIA
DEVELOPMENT SERVICES DEPARTMENT
PLANNING DIVISION
Disclosure Statement
Type or Print in Ink. Complete the following:
1. Description of the real estate affected. List the addresses of all property that is affected by the application.
Provide the lot, block, section, and subdivision of all parcels only if the properties have not been
subdivided.
Address(es)___________________________________________________________________________
Lot(s)___________________________________ Block(s)______________________________________
Section(s)________________________________ Subdivision___________________________________
2. Is the owner of said real estate, a corporation whose stock is traded on a national or local stock exchange
and having more than five hundred (500) shareholders?
No
Yes
If “Yes”, give the name of the corporation and skip to Item 4.
3. List the names, addresses, and nature of interest of ALL persons having equitable ownership of the real
estate to be affected, including, in the case of corporate ownership, the names of stockholders, officers,
and directors; and of ALL real parties of interest.
PARCEL ADDRESS NAME ADDRESS NATURE OF INTEREST
4. I hereby certify that this is a true and accurate disclosure of all persons having equitable ownership real
estate to be affected and of all the parties in interest.
______________________________
Applicant’s Signature
______________________________
Applicant’s Address
State of Virginia
County of __________
Subscribed and sworn before me this __________________ day of ________________________, 20_____.
Notary Public________________________________ My Commission Expires_____________________
