HomeMy WebLinkAboutPM 2004-36 - Agreement/Covenant - 10/23/2008 (2) WHEN RECORDED MAIL TO:
LL
QCity Clerk
(.) City of Fresno
Lu 2600 Fresno Street 10/23/2008,20080150048
U) Fresno, CA 93721-3603
4
W
CIL
NO FEE -Government Code 6103
CITY of FRESNO
Planning and Development Department
P.W. File No. 5494-2004-36
STATEMENT OF COVENANTS AFFECTING LAND DEVELOPMENT
DEFERRING CERTAIN SEWER CONNECTION CHARGES, WATER
CONNECTION CHARGES, URBAN GROWTH MANAGEMENT FEES AND
DEVELOPMENT FEES TO THE TIME OF ISSUANCE OF CERTIFICATE
OF OCCUPANCY AND CREATION OF LIEN FOR
PARCEL MAP NO. 2004-36
Statement of Covenants
Fee Deferral
PM 2004-36
Page 2
RECITALS
WHEREAS, FANCHER CREEK PROPERTIES, LLC., a California Limited Liability
Company, hereinafter referred to as the "Covenantor," is the owner of that certain real property in
the City of Fresno, County of Fresno, State of California, hereafter referred to as the "Subject
Property" and more particularly described as follows and by this reference made part of this
Statement of Covenants:
Parcels A through AQ, inclusive, and Outlots 1 and 2 of Parcel Map
No. 2004-36 according to the map thereof recorded in Book —Z,`� of
Parcel Maps at Page(s)RS•,= �-:, Fresno County Records; and
WHEREAS, Covenantor hereby warrants that any and all parties having record title interest
in the Subject Property, which may ripen into a fee, have subordinated to this instrument and all
such instruments of Subordination, if any, are attached hereto and made a part of this instrument;
and
WHEREAS, the conditions of approval of Tentative Parcel Map No. 2004-36 (hereafter,
"Project"), require the payment of applicable sewer connection charges,water connection charges,
Urban Growth Management fees, Traffic Signal Charge and/or the Millbrook Overlay Sewer fee
(hereafter, "Fees") in accordance with the provisions of Chapters 9, 11, 12 and 14 of the Fresno
Municipal Code, Resolution No. 95-117 and Resolution No. 95-118 (hereafter, "Ordinances and
Resolutions"); and
WHEREAS, said Ordinances and Resolutions provide the Covenantor the option to defer
certain Fee obligations, more particularly identified in the attached Exhibit "A", to the time of
issuance of a Certificate of Occupancy pursuant to the requirements of Section 12-4.604 of the
Fresno Municipal Code; and
Statement of Covenants
Fee Deferral
PM 2004-36
Page 3
WHEREAS, the Covenantor,as a condition of issuance of building permit(s)for the Project
pursuant to the provisions of the latest edition of the Uniform Building Code as adopted by the
State of California and as amended by the City of Fresno, including any subsequent extension and
expiration of such permit and the re-issuance of a new building permit for any expired permit on
any lot or parcel of the Subject Property, desires to defer the payment of the Fee obligations
identified in Exhibit"A" pursuant to the requirements of said Section 12-4.604 until such time that
the Covenantor or successors and assigns requests the issuance of a Certificate of Occupancy.
COVENANTS, CONDITIONS, AND RESTRICTIONS
NOW, THEREFORE, the Covenantor hereby covenants as follows:
1. For the express purpose of administering the fee deferral process, the Fee obligations
for the Project may be prorated by the City to each lot, parcel, unit or building on the Subject
Property in the manner established by the Planning and Development Director. The intent of this
provision is to prorate the Fee obligations of common use areas, outlots, public street easements
and similar miscellaneous areas of the Project in a reasonable manner to each lot, parcel, unit or
building of the Project to facilitate reasonable administration of the fee deferral process.
2. At the sole discretion of the Planning and Development Director, when the proration of
a Fee obligation is not feasible to be administered on a lot, parcel, unit or building basis, the
Covenantor may be required to pay the total Fee obligation for such fee for the Project with the first
request for issuance of a certificate of occupancy for the Project.
3. The Covenantor may elect to pay any of the deferred Fees prorated to each lot, parcel,
unit or building as identified on the attached Exhibit "B", at any time after the recordation of this
instrument. The Fee obligations stated in said Exhibit"B" shall be maintained by the Planning and
Statement of Covenants
Fee Deferral
PM 2004-36
Page 4
Development Director and shall be adjusted to reflect the Fee rates in effect at the time payment
is made,and may be adjusted to accountfor any subsequently approved reconfiguration to the size
or number of lots, parcels, units or buildings. When Covenantor elects to pay one or more of the
deferred Fees in advance of the request for issuance of a Certificate of Occupancy, the full amount
of such Fee must be paid. The remaining unpaid deferred Fees for that lot, parcel, unit or building
shall be paid in full at the time the Covenantor or successors and assigns requests the issuance
of a Certificate of Occupancy.
4. The actual Fee obligations shall be recalculated by the City at the time of payment at
the fee rates in effect at the time of such payment. For the purpose of fee recalculations, the fee
credits applied in Exhibit"A" to establish Fee obligations shall not be adjusted during the effective
term of this Statement. Any additional credits established after the recordation of this instrument
shall be reimbursed in the manner established by the section of the Fresno Municipal Code relating
to that specific Fee.
5. Additional new fee obligations not listed on Exhibit "A", but in effect at the time the
Covenantor or successors and assigns requests the issuance of a Certificate of Occupancy, will
be applicable to this Project if such new fee(s) is/are duly established by the City Council in
accordance with Government Code Section 66498.1.
6. At the sole discretion of the Planning and Development Director, a request for
"temporary utility connection" or a "temporary or safe to occupy" may be made subject to the
provision of an additional cash security deposit representing a portion or all of the deferred Fee
amounts.
7. Notwithstanding any of the above payment times, the maximum period for deferment
of Fees for a lot, parcel, unit or building shall be limited to a period of one (1) year after final
inspection of a building. This time period approximates with the Uniform Building Code and Fresno
Statement of Covenants
Fee Deferral
PM 2004-36
Page 5
Municipal Code period which provides for an active permit life of 180 days, after last inspection,
with provisions for one (1) extension of said permit, not to exceed a period of 180 days.
8. Covenantor hereby waives any claim that the provisions of this covenant violate
Government Code Section 65961.
9. Each of the covenants,conditions,and restrictions contained in this Statement shall run
with the Subject Property and shall be binding upon each successive owner of the Subject
Property, heirs, representatives, successors and assignees. The Covenantor hereby creates a lien
upon the Subject Property to guarantee the performance of the obligations of the Covenantor
contained in this Statement.
10. The conditions of this Statement are intended to benefit the public and public
properties. Accordingly, the City of Fresno shall have the right to enforce this Statement by any
legal or equitable means. All obligations of the Covenantor in this Statement shall inure solely to
the benefit of the City of Fresno. There are no third party beneficiaries of said obligations nor shall
the right of the City of Fresno be transferable in any manner to any person other than to a
successor municipal corporation whose geographic boundaries include the Subject Property.
11. In the event that litigation is instituted to enforce the processing of this covenant,the
parties agree that the prevailing party shall be paid reasonable attorney's fees.
12. The conditions and obligations of this Statement,for each lot or parcel of the Subject
Property, shall be of no further force and effect upon satisfaction of the Fee obligations for such
lot or parcel.
13. The conditions and obligations of this Statement shall remain in full force and effect
until such time as the Fee obligations for all lots, parcels, units or buildings of the Project on the
Subject Property are fully satisfied.,
Statement of Covenants
Fee Deferral
PM 2004-36
Page 6
14. The provisions of this Statement shall be deemed independent and severable and
the invalidity or partial invalidity or unenforceability of any one provision or portion thereof shall not
affect the validity or enforceability of any one provisions hereof. Whenever the context of the
Statement so requires, in interpreting this Statement, any gender includes the other genders, the
singular includes the plural, and the plural includes the singular.
Statement of Covenants
Fee Deferral
PM 2004-36
Page 7 kt
DATED: L L G i� L6 Ui,
CITY OF FRESNO, COVENANTOR
a Municipal Corporation
FANCHER CREEK PROPERTIES, LLC.,
a California Limited Liability Company
By: � _ By: Kashian Enterprises
Keith Bergthold, Assistant Dire for a imited Partnership,
Planning and Development Department as Member
�aa"�7
APPROVED AS TO FORM: Edward M. Kashian, General Partner
JAMES C. SANCHEZ
City Attorney
By: Africal Development, LLC.,
a California Limited Liability Company,
By: as Member
EJohn W. Fox
eputy City Attorney
Date: qL ((,
Thomas G. Richards, Manager
(Attach Notary Acknowledgments)
STATE OF CALIFORNIA )
) 5S.
COUNTY OF �Ytsti•n )
On Oo.l,w►-A1 IL, icoj'' before me,
personally appeared Edwgr--.1 /A• l S► �+ , personally known to
me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s)
is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the
instrument.
WITNESS my hand and official seal.
Notary Public in andsaid Sate yr
�,,,�"..•�,, STEVrN M.YOUNG
STATE OF CALIFORNIA ) COMM.#1466428
NTA"PURR-cauFORMA
COUNTY OA"o ) ss. couwr�r
On ""'I f ��, 7dV8Nhh befre me,�A• �GW (1-4- -�1ofa Y6, �-
personally appeared �C�la A5 (�. , personafly known to
me ( ", .. i amt n,. e ,.',l,",^o) to be the person(* whose name(s)
Ware subscribed to the within instrument and acknowledged to me that he/&he executed the
same in hisfiwrAheir authorized capacity(*, and that by hisAwr4kei-r signature($) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the
instrument.
WITNESS my hand and official seal. lw�v
a., L-—
Notary Public in and"d State
LETA M.CIAVAGLIA
s COMM.#1581774 M
W ?per , Notary Public�alliornla �
e FRESNO COUNTY
My Comm.Exp,June 20,2009
2 1609949.1
CLERK'S CERTIFICATION
State of California )
County of Fresno )
On October 10, 2008 before me, Sherrie L. Badertscher, Deputy City Clerk, personally
appeared, Keith Bergthold, Assistant Director of Planning and Development Department, who
proved to me on the basis of satisfactory evidence, to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the
instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal
REBECCA E. KLISCH, CMC
City Clerk, City of Fresno
By _ /r3
Deputy
EXHIBIT "A"
DEFERRED FEES AND ESTIMATED FEE OBLIGATIONS FOR PARCEL MAP 2004-36
Project Zoning: M-1/BA-15/UGM
I. WATER CONNECTION CHARGES
A. Service Connections (flat rate cost basis only)
-_ inch Services @ $_/Service = $ N/A
B. Meters (flat rate cost basis only)
- Meters to be collected at Building Permit = $ 0.00
C. UGM Transmission Grid Main (TGM) Charge
UGM Reimbursement Area: E
95.3015 Gross Acres @ $643.00 /ac. _ $ 61,278.86
Less TGM Credit = $ 95,520.00
Estimated Net Deferred UGM TGM Charge = $Paid w/ Credits
D. Transmission Grid Main Bond Debt Service Charge
95.3015 Gross Acres @ $243.00 /ac. _ $ 23,158.26
Estimated Net Deferred TGM Bond Debt Service Charge = $ 23,158.26
E. Frontage Fee
3,504 Lineal Feet @ $ 6.50 /LF = $ 22,776.00
Estimated Net Deferred Frontage Fee = $ 22,776.00
F. 1994 Bond Debt Service Fee
501 1994 Bond Debt Service Area.
267 Living Unit Equivalents @ $ 93.00/ Unit = $ 24,831.00
Estimated Deferred 1994 Bond Debt Service Fee = $ 24,831.00
G. The following water connection charges are not deferrable or prorated
under the terms of this covenant:
1. Service Connections for common, landscape and other miscellaneous
areas, and Time & Materials cost basis
2. Meters for common, landscape and other miscellaneous areas, and Time
& Materials cost basis
3. UGM Water Supply Fee
4. Wellhead Treatment Fee
5. Recharge Fee
II. SEWER CONNECTION CHARGES & SEWER RELATED CHARGES
A. UGM Oversize Sewer Charge
UGM Reimbursement Area: 37
613,800 Square Feet @ $0.05 / Sq. Ft. = $ 30,690.00
Less Oversize Credit = $ 7,900.00
Less Overdepth Credit = $ 0.00
Estimated Deferred UGM Oversize Sewer Charge = $ 22,790.00
B. Lateral Sewer Charge
50,000 Square Feet @ $0.10 / Sq. Ft. = $ 5,000.00
Estimated Deferred Lateral Sewer Charge = $ 5,000.00
C. Housebranch Sewer Charge = $ N/A
D. Millbrook Sewer Overlay
Net Adj Gross Ac @ $ /NAA = $ N/A
Units @ $ /Unit = $ N/A
E. The following sewer connection charges are not deferrable under the
terms of this covenant:
1. Trunk Sewer Charge
2. Wastewater Facilities Sewer Charge
III. URBAN GROWTH MANAGEMENT FEES
A. UGM Fire Station Fee
Service Area: 15
95.3015 Gross Acres @ $ 1,211.00 /GA = $115,410.12
Estimated Deferred UGM Fire Station Fee = $115,410.12
B. UGM Neighborhood Park Fee
Service Area: 2
95.3015 Gross Acres @ $ 638.00 /GA = $ 60,802.36
Estimated Deferred UGM Neighborhood Park Fee = $ 60,802.36
C. UGM Trunk Sewer Fee (Res 83-40)
Service Area: Fowler
95.3015 Gross Acres @ $ /GA = $ N/A
D. UGM Major Street Charge
Service Area: D-1/E-2
88.9275 Net Adj Acres @ $ 3,161.00 /NAA = $281,099.83
Less Estimated Major Street Credits = $223,568.00
Estimated Deferred UGM Major Street Charge = $ 57,531.83
E. UGM Major Street Bridge Charge
Service Area: D-1/E-2
88.9275 Net Adj Acres @ $ 304.00 /NAA = $ 27,033.96
Estimated Deferred UGM Major Street Bridge Charge = $ 27,033.96
F. UGM Grade Separation Charge
Service Area:
88.9275 Net Adjusted Acres @ $_/NAA = $ N/A
G. The following charges are not deferrable under the terms of this covenant:
1. UGM Major Street rights of way acquisition and construction
2. UGM Local Street rights of way acquisition and construction
3. UGM Major Street Bridge rights of way acquisition and construction
document:1wp511deferra1 pm2004-36exhibitA August 31,2007
' • EXHIBIT "B"-- PRORATED FEE OBLIGATIONS
Parcel Map 2004-36 Sewer, Water & UGM Fees DUE-DEFERRED BY COVENANT
Water Water TGM Water 1994 Sewer Sewer Fire Neighborhood Major Major
Lot Lot Frontage Bond Debt Bond Debt Lateral Oversize Station Park Street Bridge
No. Area Amount Amount Amount Amount Amount Amount Amount Amount Amount
Due Due Due Due Due Due Due Due Due
A 88852 $596.55 $606.55 $650.37 $130.96 $596.91 $3,022.78 $1,592.51 $1,506.94 $708.08
B 76101 $510.94 $519.51 $557.04 $112.17 $511.25 $2,589.00 $1,363.98 $1,290.56 $606.45
C 90589 $608.21 $618.41 $663.08 $133.52 $608.58 $3,081.87 $1,623.65 $1,536.29 $721.91
D 50136 $336.61 $342.27 $366.98 $73.90 $336.82 $1,705.69 $898.62 $850.36 $399.55
E 51808 $347.83 $353.66 $379.22 1 $76.36 $348.05 1 $1,762.49 $928.55 $878.62 $412.86
F 100954 $677.80 $689.17 $738.95 $148.80 $678.21 $3,434.52 $1,809.43 $1,712.05 $804.51
G 76766 $515.40 $524.05 $561.90 $113.15 $515.72 $2,611.64 $1,375.91 $1,302.05 $611.77
H 70160 $471.05 $478.95 $513.55 $103.41 $471.34 $2,386.88 $1,257.50 $1,189.92 $559.12
1 105181 $706.18 $718.04 $769.89 $155.03 $706.61 $3,578.38 $1,885.23 $1,783.71 $838.19
J 107302 $720.42 $732.50 $785.42 $158.15 $720.86 $3,650.44 $1,923.19 $1,819.68 $855.09
K 78368 $526.16 $534.99 $573.63 $115.51 $526.48 $2,666.14 $1,404.62 $1,328.92 $624.51
L 63943 $429.31 $436.53 $468.04 $94.25 $429.57 $2,175.44 $1,146.10 $1,084.40 $509.56
M 1 86790 $582.70 $592.48 $635.28 1 $127.92 $583.06 $2,952.66 $1,555.57 $1,471.82 $691.63
N 51727 $347.29 $353.13 $378.63 $76.24 $347.50 $1,759.83 $927.14 $877.32 $412.22
O 49475 $332.17 $337.75 $362.14 $72.92 $332.38 $1,683.17 $886.76 $838.92 $394.26
P 64708 $434.44 $441.73 $473.64 $95.37 $434.71 $2,201.36 $1,159.76 $1,097.52 $515.68
Q 57628 $386.91 $393.39 $421.82 1 $84.94 $387.15 $1,960.49 $1,032.86 $977.43 $459.25
R 72247 $485.06 $493.19 $528.83 $106.49 $485.36 $2,457.85 $1,294.88 $1,225.29 $575.75
S 77028 $517.16 $525.85 $563.82 $113.53 $517.48 $2,620.60 $1,380.63 $1,306.27 $613.84
T 387542 $2,601.93 $2,645.59 $2,836.69 $571.20 $2,603.53 $13,184.40 $6,946.03 $6,572.53 $3,088.37
U 108378 $727.64 $739.86 $793.29 $159.74 $728.09 $3,687.13 $1,942.52 $1,837.91 $863.66
V 105847 $710.65 $722.58 $774.77 $156.01 $711.09 1 $3,601.03 $1,897.16 $1,795.14 $843.51
W 75443 $506.52 $515.01 $552.22 $111.20 $506.83 $2,566.59 $1,352.18 $1,279.55 $601.22
X 1 75127 $504.40 $512.85 $549.91 $110.73 $504.71 $2,555.82 $1,346.50 $1,274.14 $598.70
Y 88927 $597.05 $607.06 $650.92 $131.07 $597.42 $3,025.32 $1,593.85 $1,508.00 $708.65
Z 83059 $557.65 $567.02 $607.97 $122.42 $557.99 $2,825.75 $1,488.71 $1,408.56 $661.90
AA 71389 $479.30 $487.34 $522.55 $105.22 $479.59 $2,428.66 $1,279.51 $1,210.71 $568.91
AB 63982 $429.57 $436.77 $468.33 $94.30 $429.83 $2,176.65 $1,146.74 $1,084.99 $509.87
AC 1 17140 $115.08 $117.00 $125.46 $25.26 $115.15 $583.10 $307.20 $290.65 $136.59
AD 67098 $450.49 $458.06 $491.14 $98.90 $450.77 $2,282.74 $1,202.63 $1,137.89 $534.71
AE 65773 $441.59 $449.02 $481.44 $96.94 $441.87 $2,237.69 $1,178.90 $1,115.52 $524.16
AF 126936 $852.24 $866.54 $929.13 $187.09 $852.76 $4,318.43 $2,275.11 $2,152.70 $1,011.56
AG 70396 $472.63 $480.56 $515.28 $103.76 $472.92 $2,394.87 $1,261.71 $1,193.97 $561.00
AH 43941 $295.02 $299.96 $321.63 $64.76 $295.20 $1,494.86 $787.55 $745.29 $350.18
Al 40083 $269.11 $273.64 $293.40 $59.08 $269.28 $1,363.71 $718.45 $679.65 $319.41
AJ 40314 $270.67 $275.20 $295.09 $59.42 $270.83 $1,371.46 $722.53 $683.71 $321.27
AK 39550 $265.54 $270.00 $289.49 $58.29 $265.70 $1,345.54 $708.88 $670.84 $315.19
AL 40749 $273.59 $278.19 1 $298.27 $60.06 $273.75 $1,386.35 $730.38 $691.08 $324.73
AM 41897 $281.29 $286.01 $306.67 $61.75 $281.47 $1,425.35 $750.93 $710.57 $333.88
AN 35942 $241.31 $245.36 $263.08 $52.98 $241.46 $1,222.75 $644.19 $609.59 $286.43
AO 143637 $964.37 $980.55 $1,051.38 1 $211.71 $964.96 $4,886.63 $2,574.46 $2,435.93 1 $1,144.65
document:\q\print\h 31-Aug-07
EXHIBIT"B"-- PRORATED FEE OBLIGATIONS
Parcel Map 2004-36 Sewer, Water & UGM Fees DUE-DEFERRED BY COVENANT
Water Water TGM Water 1994 Sewer Sewer Fire Neighborhood Major Major
Lot Lot Frontage Bond Debt Bond Debt Lateral Oversize Station Park Street Bridge
No. Area Amount Amount Amount Amount Amount Amount Amount Amount Amount
Due Due Due Due Due Due Due Due Due
AP 66606 $447.19 $454.70 $487.54 $98.17 $447.46 $2,266.02 $1,193.83 $1,129.54 $530.78
AQ 72834 $489.00 $497.20 $533.12 $107.35 $489.30 $2,477.83 $1,305.41 $1,235.28 $580.43
document:\q\print\h 31-Aug-07
SUBORDINATION
The undersigned as holder of the beneficial interest in and under that certain Deed of Trust
recorded on U-259' 67 , as Document No.2067- 02►22443 , in the office of the
Fresno County Recorder, of which the Deed of Trust in, by and between:
'Farche r C,(Cs." Ptoo•r ktes,L-LC , a C"\.O'wis Vs^dreP It -..,", as Trustor,
HL A C'f,c,; a.\ C.aw.��� , as Trustee, and
n� Cclre4s6a4'i oh, as Beneficiary,
hereby expressly subordinates said Deed of Trust and its beneficial Interest thereto to the
foregoing Statement of Covenants Affecting Land Development for Deferring Certain Sewer
Connection Charges, Water Connection Charges, Urban Growth Management Fees and
Development Fees to the Time of Issuance of Certificate of Occupancy and Creation of Lien for
Parcel Map No. 2004-36.
L t
DATED:
BENEFICIARY
Tc-
By:-
c-By: � vL '5
-'�o rr\a s M. l.•� �►�
vice -'Pces►cAeY.�
By:
(Beneficiary to print/type Name and Title; and
attach Notary Acknowledgment)
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of Placer
On January 22, 2008 before me,Wendy Todhunter 0QTY polut
DATE NAME,TITLE OF OFF CER"
personally appeared Thomas M. LyLin--------------------------------------------------------------------
NAME(S) OF SIGNER(S)
who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal. WENDY TOULI
DHcC
UAA
NTER 3
COMM.#1755553
NOTAp�CER COUNLT`� RNIA
SIGNATURE OF NOTARY Comm.Exp•AUG.1,2011
This area for notarial seal
OPTIONAL
Though the data below is not required by law, it may prove valuable to persons relying
on the document and could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNED DESCRIPTION OF ATTACHED
DOCUMENT
QINDIVIDUAL Subordination
❑ CORPORATE OFFICER TITLE OR TYPE OF DOCUMENT
TITLE(S)
❑ PARTNER(S) ❑ LIMITED P l uS �
❑ GENERAL ^^ rNUMBER O PAGES
11 ATTORNEY-IN-FACT • a',,a-• L Li
Cl TRUSTEE(S) DATE OF DOCUMENT
❑ GUARDIAN/CONSERVATOR
❑ OTHER:
SIGNER(S)OTHER THAN NAMED ABOVE
SIGNER IS REPRESENTING: