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………………. BELEDİYE BAŞKANLIĞI
İmar ve Şehircilik Müdürlüğüne
……………………. İlçesi, ………………………….. Mah. ……..……. pafta, …..……. ada, ……….. parsel sayılı taşınmazın adresinin ilgili makama verilmek üzere tarafıma verilmesini arz ederim.
Ad-Soyad (İmza)
ADRES: