For an appeal by right of this decision to be timely, it must be made to the court of proper jurisdiction within 30 days of the date of this order.

1) Appeal Number: _________________

2) Hearing Date: ___________________

3) Applicant: _____________________________________________

4) Address: ______________________________________________
________________________________________________________

5) Phone: _________________________

6) Purpose of request: (variance, interpretation of zoning map, administrative appeal, other—please specify): ________________________________________________________
________________________________________________________

7) ZBA Findings of Fact:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

8) ZBA Decision: ________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

9) Reasons for Decision:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

10) Vote of ZBA Members:

(Yes) (No) ______________________
(Yes) (No) ______________________
(Yes) (No) ______________________
(Yes) (No) ______________________
(Yes) (No) ______________________

11) Signature(s) of Designated ZBA Members:

___________________________________________

___________________________________________

___________________________________________


I, __________________, Secretary of the _____________ Township Zoning Board of Appeals, certify that on this date I witnessed the signatures set forth above and attest to the accuracy of this report.

___________________________________