I, _________________________________, owner of ____________________________

have been made fully aware of the Rules and Regulations of Shadow Lake Village, stating that unit owners are responsible for the maintenance of specific interior structures of the chimney which require cleaning annually. I am also aware that our general insurance carrier, when preparing insurance for Shadow Lake Village expects that records be kept on file stating if and when chimneys were last inspected for fire hazards. I am signing this affidavit to keep on record that the chimney, at above address, has not been in use since January 1, 2007.

___________________________________ _____________________

(Owner Signature) (Date)

FORM MUST BE SUBMITTED BY MARCH 15, 2008 AS RECORD THE CHIMNEY WAS NOT IN USE THE PRIOR YEAR.