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12. Signature of Authorized Representative of Certi�ed Local Governmen � <br /> t <br /> � . Signature , <br /> �. ����� � S o� c� �., �. � <br /> Printe Name, Title j <br /> �o�cv�,b�r- t� , � o o -��'' �',I <br /> Date <br /> 8 <br /> RETURN APPLICATIONS TO: <br /> ILLINOIS HISTORIC PRESERVATION AGENCY <br /> PRESERVATION SERVICES DIVISION <br /> 1 OLD STATE CAPITOL PLAZA <br /> SPRINGFIELD, ILLINOIS 627Q1 <br /> ' ATTN: TERRI MALAWY <br /> MUST BE POSTMARKED BY NOVEMBER 12, 2005 <br /> 22 <br /> � , . <br />