Variance Sanctions Request

Variance Sanctions Request

Requestor Information

Requestor Name

Requestor Email Address

Requestor Phone Number

Sanction Being Request on Behalf of

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State how you are affected by the variance

Reason for Requesting Sanction

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Sanction Requested

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Variance Number

This is the number assigned to the variance application (i.e., XX-XX-XX).

Owner/Applicant Name

Owner/Applicant Email Address

Owner/Applicant Phone Number

Submitter Name

Submitter Email Address

Submitter Phone Number

Any Additional Information to Support Your Request

Please upload a copy of the final action letter (final order) of the variance. Variance final action letters may be searched for here: https://www.in.gov/dhs/boards-and-commissions/variance-database-search/. Also upload any supporting documentation.

File Upload

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