150 Des Moines Street
Des Moines, IA 50309-1836
Complete the entire form. Submit the completed form, supporting documents and $100.00 check or
money order to the address above.
This request will be denied if more than 12 months have passed since the initial application was received.
Individual Completing Form
Duration of extension request:
(length must be justified) 30 days 60 days
Describe in detail the reason for the extension
Submit this request during the 10
month of permit issuance - IAC 71.5(6)
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