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DRAFT Declarations, Covenants, Restrictions 05-2008.pdf DECLARATION OF EASEMENTS, COVENANTS, CONDITIONS, AND RESTRICTIONS FOR THE PLAT OF GREENNESS EDMONDS, WASHINGTON May 2008 DRAFT THIS DECLARATION HAS NOT BEEN RECORDED PREAMBLE We, the owners and residents of GREENNESS join together to create, maintain, and share an environmentally beneficial and aesthetically inspiring community. Through an economy of means and use of renewable and recycled resources manufactured free of toxins, we aspire to help the planet attain a safer and more equitable and sustainable balance of its needs and resources. DECLARATION THIS DECLARATION OF CONDITIONS, RESTRICTIONS, COVENANTS, AND EASEMENTS is made as of this _____ day of _____________, 2008, by Green Tara Incorporated, a Washington State Domestic Profit Corporation, Phillip and Mariam Lehn, and __________________________________(Declarants) owners of real property (Property) in Snohomish County, Washington, legally described in. Legal Description: See Exhibits A through F attached hereto (Should exhibits include improperly recorded documents?) Exhibit A: Corrected Greenness 4 Lot Short Subdivision, Recorded May 31, 2002 Exhibit B: Boundary Line Adjustment, Recorded September 17, 2004 Exhibit C: Utility Easement, Recorded April 27, 2006 Exhibit D: Final Lot 2 Short Plat Approval – Pending Exhibit E:GREENNESS SITE MAP, April 6, 2008 Declarants hereby declare that all of the Property shall be held, sold, and conveyed subject to the following easements, restrictions, covenants, conditions, charges, and liens (hereinafter collectively referred to as “Covenants”) all of which are for the purpose of protecting and enhancing the Property’s use and value. The Covenants shall run with and burden the Property and shall be binding upon all of the parties having or acquiring any right, title, or interest in the Property or any part thereof and shall be binding upon their heirs, successors, and assigns, and shall inure to the benefit of each Owner thereof. Declarants hereby delegate and assign to the Association the power of administering and enforcing the Covenants and collecting and disbursing the assessments created in this Declaration. I - DEFINITIONS 1.1“Approval” shall mean written approval, the written waiver, or the issuance of a letter of “no objection”. 1.2“Association” shall mean and refer to The Greenness Community Association, its successors and assigns. The Greenness Community Association shall administer the community’s Common Areas and improvements for the benefit of all Members. 1.3“Buildable Area” is that property within each lot so designated in Exhibit F: GREENNESS SITE MAP that can be built upon. While lot lines and setbacks are as required, it is understood that areas identified on the MAP as “Buildable” are intended to be approximate and may be adjusted to accommodate a particular design’s requirements with the approval of the Greenness Design Council. 1.4“Community” shall mean the community of Greenness Lot Owners and Residents. 1.5“Common Open Space” shall mean all property maintained by the Association for the common enjoyment of the Plat’s Residents identified as a Common Open Space in GREENNESS SITE MAP”. Common Open Space Exhibit F: “ Areas shall include all real property and improvements located between the designated outer perimeter of each Lot’s Buildable and Private Open Space Areas and its lot lines. 1.6“Common Paved Area” shall mean all paved road and vehicular turnaround areas identified as such in Exhibit E: GREENNESS SITE MAP”. Maintenance and repair of this area shall be as specified in the Plat’s Dedications. “ 1.6 “Declaration” means this Declaration as it may be amended from time to time. 1.7 “Declarants” shall mean Green Tara Incorporated, Phillip and Mariam Lehn, _________________________________ and their successors and assigns. 1 5/25/2008 DRAFT 1.8 “First Mortgagee” means a lender who holds a first mortgage or deed of trust against a Lot and who has so notified the Association in writing. 1.9 “Greenness” shall mean the Greenness Plat as recorded with the Snohomish County Auditor. 1.10 “Lot” means any parcel identified in : GREENNESS SITE MAP as Lots A through E. Exhibit F 1.11 “Member” means every person or entity holding membership in the Association and as further defined in Section 3.1. 1.12 “Notice” means written notice delivered personally or mailed to the recipient’s last known address. 1.13 “Owner” means the owner of record, whether one or more persons or entities, of a fee simple title to any lot which is a part of the Property, and contract purchasers, excluding those having such interest merely as a security for performance of an obligation and excluding contract sellers. “Owner” shall also include any person or persons or entities holding a leasehold interest in any lot. 1.14Plat” means the GREENNESS Plat as recorded with the Snohomish County Auditor. 1.15“Private Open Space” means all property identified as such in Exhibit E:GREENNESS SITE MAP and shall include each Lot’s private outdoor areas. The Design, installation, maintenance, and repair of this area shall be the responsibility of each Lot’s Owner as approved by the Greenness Design Council. 1.16“Private Paved Area” means all property identified as such in Exhibit E:GREENNESS SITE MAP and shall include each lot’s private paved areas. Installation, maintenance, and repair of this area shall be the responsibility of each Lot’s Owner. 1.17“Property” and “Properties” means all real property located within the GREENNESS Plat. 1.18“Resident” means anyone who resides in one of the Plat’s residences. 1.19“Shared Open Space (A&E)” means that area so designated in Exhibit E: GREENNESS SITE MAP. The use, maintenance, and improvement of this area will be shared in common between the Lot Owners of Lots A and E. II - RESTRICTIONS 2.1 Permitted Uses. No lot within GREENNESS shall be used for any purpose except as hereafter permitted in this Section and the City of Edmonds Municipal Code. Excepting Common Area improvements approved by a majority of the Lot Owners, no building or structure shall be erected, altered, placed or permitted to remain on any lot other than one detached single family dwelling and its garage. . All buildings, landscaping, and subsequent improvements shall aspire to manifest the 2.2 Design and Construction highest standards of design and craftsmanship. The construction of all buildings and structures shall be prosecuted diligently and continuously until completed. The design and construction of all buildings, alterations, additions, and landscaping shall be approved by the Greenness Design Council who shall be selected by and represent a majority the Association’s Members. 2.3 Notice. “Notice” means written notice delivered personally or mailed to the recipient’s last known address. Uses or things considered disturbing or a nuisance to a majority of the Association’s Members shall not 2.4 Nuisance. be permitted. 2.5 Garbage. No garbage or recyclable wastes shall be deposited on or left anywhere on the exterior of any Lot, except in waste and recycling receptacles and transfer stations as designated and approved by the Association. 2.5 Compost. Yard rakings, weeds, cuttings, dirt, and other organic materials resulting from private and common landscaping work shall not be deposited onto Common Areas except in those common composting areas designated on the Greenness Site Map. Material deposited onto the common composting areas shall be free of toxic sprays, weed killers, insecticides, etc. 2.6 Fences. To preserve and enhance the visually flowing, and interconnected nature of the plat’s open spaces, no visible fences shall be permitted to separate lots and private and common open spaces. 2.7 Recreational Equipment and Temporary Dwellings. No motor home, travel trailer, recreational vehicle, utility trailer, watercraft (on or off trailer) may be parked within a designated Private or Common Open Space area for more than 90 days. Use by anyone of any of the above as auxiliary or accessory occupancy to a residence is prohibited. 2.8 Vehicles. No inoperable vehicles, motorcycles or other motorized apparatus shall be stored within a designated Private or Common Open Space area. No mechanical repairs shall be conducted on the same designated areas, 2 5/25/2008 DRAFT except minor maintenance and mechanical work by a resident of the Property on said resident’s private vehicle, provided that any such conduct be in a manner which is not offensive to persons residing in GREENNESS, is not unsightly, and does not result in unusual noise or debris being placed on the Property. No Owner shall permit any vehicle which is in an extreme state of disrepair to be abandoned or to remain parked on any part of the Property’s Private or Common Open Space areas for more than forty-eight (48) hours. 2.9 Pets. A Lot Owner may keep pets within their lot’s private areas provided that they do not threaten any other resident’s safety, injure property, or disturb the community’s peace. Pets shall not be allowed to roam free and unattended throughout Common Areas and Residents shall be responsible for the removal and proper disposal of their pet’s feces. 2.10 View Protection. No tree that could impair any lot’s view of Puget Sound and the Olympic Mountains shall be planted subsequent to the adoption of this Declaration. Planting, pruning and selective tree removal within each lot’s Common Areas shall be administered by the Association. Trees planted on Lots A, D and E subsequent to the adoption of this Declaration shall not exceed a height of 30 feet unless otherwise approved by the owners of Lots B and C (subsequent to the recording of Lot 2’s subdivision). 2.11 Landscaping. Common Area landscaping planting, maintenance, and removal shall be provided by qualified landscaping professionals approved by a majority of the Association’s Members. The work shall be consistent with the GREENNESS SITE MAP as amended from time to time by a majority of the Association’s Members. Each Owner shall pay the cost of maintaining all Common Areas located on their lot. III THE ASSOCIATION 3.1Membership. Every Owner of a lot shall be a Member of the Association. Membership shall be appurtenant to and may not be separated from ownership of any Lot. Ownership of a Lot shall be the sole qualification for membership. 3.2 Class. The Association shall have a single class of voting membership. Each Member shall be entitled to one (1) vote for each Lot owned. When more than one person holds an interest in any Lot, all such persons shall be Members. The vote for such Lot shall be divisible and exercised as the Owners determine, but only one vote shall be cast for any Lot. . The Association shall hold meetings at such times and for such purposes as may be necessary to 3.3 Operation conduct the business of the Association. Any Member may call a meeting on no less than thirty (30) days notice to all other Members and the attendance of Members holding at least three votes shall be a quorum. All decisions, except those amending this Declaration, shall be made by a minimum of three votes. This Declaration may be amended by a unanimous vote of the Lot Owners. The Association shall have such powers as are reasonably necessary for the performance of its functions. The Members shall elect an agent to serve each year as representative of the Members to perform the various duties outlined in these covenants including but not limited to, collecting assessments, hiring vendors, and paying Association bills. IV COMMON & PRIVATE AREAS 4.1Common Open Areas. Declarants hereby convey administration, improvement, insuring, and common maintenance of the Common Open Areas, as described in Section 1.3, to the Association for the mutual benefit of all Owners. Common Open Areas includes those areas so identified in Exhibit E: GREENNESS SITE MAP. Each lot Owner and Resident and their guests shall have access through and use of Common Areas within their lot. Each Owner shall plan, improve, and maintain their Lot’s designated Common Areas subject to the Greenness Design Council’s approval for a year from the date of the completion of the improvements’ installation. Thereafter those Common Areas shall be maintained by the Association. 4.2Private Open Areas. Private Open Areas shall consist of all real property so designated in Exhibit E: GREENNESS SITE MAP located between each Lot’s building(s) and the community’s Common Open Areas. Private Open Areas are reserved for each lot Owner(s) exclusive use, administration, and maintenance. The design and installation of permanent landscaping within Private Open Areas shall be subject to the approval of the Greenness Design Council. The Plat’s road and emergency vehicular turn around designated “Common Paved Area” 4.2Common Paved Areas. in Exhibit E: GREENNESS SITE MAP shall be commonly administered and maintained as required by the Plat’s Dedications. Each Lot’s private paved areas shall be designed, installed, and maintained by each Lot’s 4.3Private Paved Areas. Owner as approved by the Greenness Design Council. 3 5/25/2008 DRAFT 4.4Guest Parking, Main Pathway & Stairs. The two guest parking spaces accessed from the road’s vehicular turn around and the main pathways through the orchard and bamboo tunnel, and the stairs between lots A and E and B and C shall be commonly administered and maintained. 4.5Conveyance. Conveyance of a Lot includes the exclusive rights to the use of the Private and Common Areas of that Lot, as set forth, above. V ASSESSMENTS AND LIENS 5.1Purpose. Assessments are needed to protect and enhance each Owner’s investment by satisfying their shared obligation to establish, maintain, and improve Common Areas. To that end each Lot Owner shall be assessed the cost of maintaining their Lot’s Common Areas. The assessments levied by the Association shall be used exclusively by the Association for the performance of its obligations under Section 8.1 for administrating, improving, insuring, and maintaining Common Areas. 5.2Assessments. Each Lot Owner by acceptance of a deed therefore, whether or not it shall be so expressed in any such deed or other conveyance, is deemed to agree to pay to the Association (1) regular assessments or charges (monthly, quarterly, or annually), and (2) special assessments for capital improvements. The initial regular assessment shall be $25 / month commencing on the date this Declaration is signed by all Declarants, due and payable on the 1 day of each month, each third month, or each year. st 5.3Determination of Regular Assessments. The Association shall fix the regular assessment at least thirty (30) days prior to the start of the fiscal year. Any fee surplus collected but not spent during the previous year shall be divided proportionately amongst the five lot Owners and credited towards each Owner’s current assessment. Written notice of the regular assessment shall be sent to every Owner. In the event the Association fails to fix an annual assessment for any fiscal year, then the assessment established for the prior year shall be continued automatically until such time as the Association acts. The annual assessment shall be sufficient to meet the obligations imposed by this Declaration and any supplementary declaration, and shall be sufficient to establish an adequate reserve fund for the performance of the Association’s maintenance, repair, and replacement obligations under Section 8.1. In addition to the regular assessments authorized above, the 5.4Special Assessments for Capital Improvements. Association may levy a special assessment applicable to that year only for the purpose of defraying, in whole or in part, the cost of any construction, reconstruction, major repair, or replacement of a capital improvement in the Common Area that is approved by four Members who are voting in person or by proxy at a meeting duly called for the purpose. 5.5Rate of Assessment. Both regular and special assessments shall be fixed according to the amount required by each lot except as otherwise agreed by a vote of four of the Plat’s five members. 5.6Liens. Regular and special assessments, together with interest, costs and reasonable attorney’s fees shall be a charge and continuing lien upon the Lot against which each such assessment is made. Such lien may be foreclosed by the Association in the same manner as a mortgage on real property. 5.7Insurance. Each lot Owner(s) shall obtain and maintain adequate homeowners’ insurance to protect themselves, their guests, and their property. Each lot Owner(s) shall supply the water needed by the Association’s to maintain and improve Common 5.8Water. Areas located on that Owner(s)’ lot. 5.9Obligation. Each assessment, together with interest, costs, and reasonable attorney’s fees shall also be the personal obligation of the person who was the Owner of the Lot at the time the assessment fell due. The personal obligation shall not pass to the Owner’s successors-in-interest unless expressly assumed by them. The new Owner shall be personally liable for assessments which become due on and after the date of sale or transfer. Any assessment which is not paid when due shall be delinquent. A late charge equal to five 5.10Nonpayment. percent (5%) of the amount overdue shall be charged for any payment made more than thirty (30) days past the due date. If the assessment is not paid within sixty (60) days after the due date, the assessment shall bear interest from the due date at the rate of twelve percent (12%) per annum, and if not paid within ninety (90) days the Association may file a lien against the Lot. The Association may initiate a legal action against the Owner obligated to pay the assessment, or, when deemed necessary, may foreclose on the lien after sixty (60) days but prior to ten (10) years from date of assessment, and in either event, interest, costs, and a reasonable attorney’s fee shall be added to the amount of such assessment. No Owner may waive or otherwise escape liability for quarterly or special assessments by nonuse of the Easements or by abandonment of his or her Lot. 5.11Establishment of Lien. Such amount as established pursuant to Section 5.10 shall constitute a lien against the property of the owner upon a notice of such lien being recorded with the Snohomish County Auditor. Such lien shall continue in effect until foreclosed upon or upon the expiration of the period for which a judgment lien is valid in the State of Washington, whichever is sooner. 4 5/25/2008 DRAFT 5.12Suspension. The Association shall have the power to suspend the voting rights of any Owner or persons to who the Owner has delegated use pursuant to Section 4 for any period during which an assessment, special assessment, or charge established pursuant to Section 5 remains unpaid or during any period in which the Owner is in violation of any of these Covenants or any published rule or regulation of the Association. 5.13Fiscal Year. The fiscal year of the Association shall commence on January 1 and shall end on the subsequent December 31. VI EASEMENTS Declarants hereby grant, declare, and reserve the following easements. 6.1Easements. 6.2Utility Easements. Utility, sanitary sewer, storm water, waste transfer, and other easements on the Property benefiting and burdening the Lots as indicated on the Final Lot 2 Short Plat Documents (Exhibit D). 6.3Access Easements. All lots shall share vehicular and pedestrian Access Easements through designated portions of the Plat for the limited purpose of improving and maintaining Common Areas. These portions shall include the Plat’s road and emergency vehicular turn around, the two guest parking places adjacent to the emergency vehicular turn around, the Plat’s main pathway through the orchard and bamboo tunnel, and the stair between lots A and E and B and C. 6.4Association Easements. The Association shall have a common access easement for the operation, maintenance, and repair of all Common Areas. The Association shall also have an access easement to the exterior of any building during reasonable hours as may be necessary for the following purposes: 6.4.1The operation, maintenance, and repair of the Common Area and all improvement thereon. This duty shall include, but shall not be limited to irrigation, removal of plant material which impairs the Common Area’s operation or aesthetics, and the maintenance of utilities, paths, stairs, and retaining walls. 6.4.2The installation, maintenance, repair, and necessary replacements of improvements within the utility, sanitary sewer, storm water, waste transfer, and other easements as designated on Exhibit A, B, C, and D and as may be needed to serve the Plat. 6.4.3The cleaning, maintenance, or repair of any Lot or improvement thereon of and to the extent permitted under Section 4. 6.4.4The maintenance, repair, replacement, or improvement of any Easement accessible from that Lot. 6.4.5Emergency repairs necessary to prevent damage to the Easement or to another Lot, or the improvements thereon. 6.5Restrictions. Each Owner shall have an exclusive right to use the Easements located on their lot for the purpose intended, subject to: 6.5.1Dedications listed in the Plat Documents (see exhibits A, B, C, and D) 6.5.2The right of the Association to adopt reasonable rules governing use of the Easements and the personal conduct of persons authorized to use said areas for installation or maintenance of facilities or improvements located within the Easements. 6.5.3The right of the Association to dedicate or transfer by deed or Easement all or any part of the Easements to any public agency or authority, or public or private utility. No such dedication or transfer shall be effective without the approval of a majority of the Members, and approval by the First Mortgages. VII DESIGN APPROVAL 7.1 Establishment. The Greenness Design Council shall consist of three Members selected by the Association for staggered terms lasting three years. 7.2.1Intent. Members of Greenness aspire to share an environmentally beneficial and spiritually inspiring community of healthy and beautiful homes and open spaces requiring minimal energy and maintenance. By minimizing their use of non-renewable resources and maximizing their use of renewable and recycled resources manufactured free of toxins, the Members of Greenness aspire to help the planet attain a safer, more equitable and more sustainable balance of its needs and resources. 7.3Approval. No building, site improvement, or landscaping of any kind shall be erected, placed, or altered on any Lot or Common Area within the Property until its design and construction drawings and specifications have been reviewed and approved in writing by the Greenness Design Council. In the event that the Council fails to approve or reject a complete and properly prepared application in writing within 90 days of its submission, the Council’s approval will not be required and this article will be considered fully complied with. 5 5/25/2008 DRAFT 7.4Landscape Design. Along with design and construction documents for their proposed building and improvements, each Owner shall submit a detailed landscaping plan for the building’s Lot showing the location and common name of all proposed plants, hard surfaces, and features. Such landscaping shall help implement and be in harmony with the Community’s landscaping plan for its shared Common Areas. No permanent landscaping feature or plant shall be provided or removed from any lot’s Common Areas without the Greenness Design Council’s approval. 7.4.1Rules and Costs. The Greenness Design Council shall consider and act upon all matters properly submitted to it. In furtherance of its purpose, the Council may by unanimous vote, adopt, amend, and repeal rules and regulations to be known as the Greenness Design Rules establishing its operating procedures. The Council shall charge applicants a reasonable fee to cover the costs of its reviews. A current copy of the Greenness Design Council’s rules and fees shall be kept on file at the principal office of the Association. Such rules and fees shall have the same force and effect as if set forth herein. Any approval by the Council shall not constitute a precedent or waiver impairing its right to withhold or grant an approval for any similar matter subsequently submitted. VIII MAINTENANCE REPAIR AND REPLACEMENT 8.1Association Obligations. The Association shall be obligated to maintain, repair, and where necessary replace the following: 8.1.1.Common Areas. All improvements within the Plat’s designated Common Open and Paved Areas. 8.1.2.Landscaping. Each lot’s Owner(s) shall pay the cost of installing and maintaining the approved landscaping for a period lasting one year from its installation’s completion. Thereafter, the Association shall be responsible for maintaining and replacing trees, shrubs, groundcovers, terraces, and pathways in the Common Open Areas. The Owner(s) of each lot shall maintain their own Private Open Areas in accordance with plans for those areas approved by the Greenness Design Council. 8.1.3.Mailboxes and Waste Transfer Areas. 8.1.4.Expenses. Expenses incurred in performing this work shall be paid for by the Association and become part of the assessments described in Section 5. However, any work required as a result of a negligent or intentional act or omission of any Owner or his or her guests, family, agents, or tenants shall be paid for exclusively by such Owner and shall become part of the assessments levied against the Lot owned by such Owner. Each Owner shall be obligated to maintain his or her building(s) and all landscaping located 8.2Owners’ Obligations. in the Private Open Areas adjacent to the lot’s building(s), in good order, condition, and repair. If the Owner of any Lot fails to so maintain the Lot’s building(s) and Private Open Areas to those standards and allows the Lot’s building(s) and Private Open Areas to fall into gross disrepair negatively affecting property or rental values in the Greenness Plat, the Association, after approval by three of the Plat’s five Lot Owners, shall have the right, through its agents and employees, to enter upon the Lot and to clean, repair, maintain, and restore the Lot and the exterior of the buildings and other improvements, provided, however, that any structural alteration or demolition of constructed improvements may only take place after judicial proceedings are instituted. The cost of such exterior maintenance and all court costs, and attorney’s fees incurred in enforcing this provision shall be added to and become part of the assessments for such Lot. IX GENERAL PROVISIONS 9.1Compliance. All present and future Owners or occupants of Lots shall be subject to and shall comply with the provisions of this Declaration and as they may be amended from time to time. The acceptance of a deed or conveyance or the entering into occupancy of any Lot shall constitute an agreement that the provisions of this Declaration as they may be amended from time to time, are accepted and ratified by such Owner or occupant, and all such provisions shall be deemed and taken to be covenants running with the land and shall bind any person having at any time any interest or estate in such Lot, as though such provisions were recited and stipulated at length in each and every deed and conveyance or lease. 9.2Critical Areas. All property Owner(s) are advised that some of the Property is located within or joins areas the City of Edmonds considers “Critical” or “Geologically Hazardous”. Owner(s) are also advised to familiarize themselves with the City’s relevant studies and ordinances and the Developer’s geotechnical reports. 9.3Any Owner shall have the right to enforce, by any proceedings at law or in equity, all easements, restrictions, conditions or covenants imposed by the provisions of this Declaration. 9.4No delay or omission on the part of the Declarants or any other Owner in exercising any rights, power, or remedy provided in this Declaration shall be construed as a waiver of or acquiescence in any breach of the covenants, conditions, reservations, or restrictions set forth in this Declaration. No action shall be brought or maintained by 6 5/25/2008 DRAFT anyone whatsoever against the Declarants for or on account of its failure to bring any action for any breach of these covenants, conditions, restrictions, or for imposing restrictions which may be unenforceable. 9.5Invalidation of any one of these covenants or restrictions by judgment or court order shall not affect any other provisions which shall remain in full force and effect. 9.6This Declaration and the easements, covenants, conditions and restrictions herein shall be appurtenant to and shall run with the Property and shall burden and be for the benefit of each subsequent owner of the Property or any portion thereof. 9.7This Declaration may be amended to impose new restrictions on any Lot only with the written consent of all persons holding any interest in such Lot. Other provisions of this Declaration (except for this Section which may be amended only with unanimous consent of all Members) may be amended only with the written consent of 4 of Greenness’ 5 shares of ownership. IN WITNESS WHEREOF, the undersigned has caused this Declaration to be executed on this _____ day of ________________________, 2006. By: __________________________________________________ Gnendak Shak, President - Green Tara Incorporated __________________________________________________ ___________________________________________________ Phillip Lehn Mariam Lehn __________________________________________________ STATE OF WASHINGTON ) )ss. County of King ) On this ____ day of _________________, 2006, before me, the undersigned, a Notary Public in and for the State of Washington, duly commissioned and sworn, personally appeared Gnendak Shak, known to be the President of Green Tara Incorporated, a Domestic Profit Corporation, Phillip and Mariam Lehn, and Chris Young and Stella Kondilis known to be the individuals described in and who executed the foregoing instrument, and acknowledged that he or she signed such instrument as their free and voluntary act and deed for the uses and purposes therein mentioned. WITNESS my hand and official seal hereto affixed the day and year first above written. ____________________________________ ____________________________________ (Type/Print name) Notary Public in and for the State of Washington Residing at ________________________________________________ My Appointment Expires: ___________________________________ 7 5/25/2008 DRAFT