HomeMy WebLinkAboutCorrespondencePlan Review - Review Comments Report
Project Name: PZ-2023-00231, 00208 V - Whiteley Detached Garage Variances
Workflow Started: 9/22/2023 12:40:08 PM
Report Generated: 05/30/2024 11:13 AM
REF #CYCLE REVIEWED BY TYPE FILENAME DISCUSSION STATUS
1 1 Engineering
Alex Jordan
9/26/23 9:18 AM
Comment
We have no concern with the variances but will hold on this item until the
consent to encroach is voted on by the Board of Public Works.
Info Only
2 1 Planning & Zoning
Angie Conn
9/26/23 12:19 PM
Comment
Please respond in writing to the preliminary review comments listed at the
bottom of the 9/22 docket no. assignment email, and please do that before
noon Oct. 13 - for your convenience, they are listed again, below: a) Please
make checks payable to City of Carmel if you are paying via check. b) Provide
a copy of the Official List of Adjacent Property Owners from the Hamilton
County Auditors Office. (Make sure to check Carmel BZA on their form.) c)
*The Current in Carmel only prints on Tuesdays, and their filing deadline is
usually 14 days prior to their printing date. Please submit your Microsoft
Word file of the legal ad to them before Noon, Friday Sept. 29 so that it
prints on time. Their contact info is 317-489-4444 or
legals@youarecurrent.com. (Please refer to the Handout for a template of
wording to use for the legal ad and the mailings the Notice of Public
Hearing.) d) The mailings/notices to the neighbors should be done by first
class mail with Certificate of Mailing (not Certified Mail). (Please provide us
with the certificate of mailings for the file on or before noon Wed., Oct. 18.)
e) Please provide the filled out & notarized Placement of Public Notice Sign
Placement Affidavit form (found in Handout) once the sign is placed. f)
Please provide the filled out & notarized Petitioners Affidavit of Notice of
Public Hearing form (found in Handout). g) Please provide the filled out
Notice of the Public Hearing form/template (found in Handout). h) Please
provide proof of notice, such as Publishers Affidavit from the newspaper,
once you receive them. i) Please make sure to list out your practical
difficulties and hardships associated with having to comply with the zoning
ordinance. j) Additional review comments (if any) will be issued through
ProjectDox, our online electronic plan review software.
Responded by: Jason Whiteley - 5/14/24 4:28 PM
All of the needed items on this list have been completed
and submitted
Resolved
3 1 Planning & Zoning
Angie Conn
9/26/23 12:20 PM
Comment
Consent to Encroach approval will be required by the Carmel Engineering
Dept. Please create and submit that application on the online application
portal: https://cw.carmel.in.gov/PublicAccess/template/Login.aspx
Responded by: Jason Whiteley - 5/14/24 4:28 PM
Carmel Engineering has approved the Consent to
Encroach and the application has been submitted and
recorded
Resolved
4 1 Hamilton County
Surveyor
Samuel Clark
10/11/23 4:11 PM
Comment
A SINGLE TRACT NONENFORCEMENT WILL BE REQUIRED FOR THE
ENCROACHMENT OF THE GARAGE INTO A REGULATED DRAIN EASEMENT. I
HAVE UPOADED THE NECESSARY APPLICATION TO THIS FILE. PLEASE FILL
OUT AND SUBMIT THE APPLICATION ALONG WITH THE SITE PLAN TO OUR
OFFICE. CONTACT US AT 317-776-8495 IF YOU HAVE ANY QUESTIONS
Responded by: Jason Whiteley - 5/14/24 4:27 PM
My apologies, but I'm just seeing this unresolved issue. I
believe this application has been completed and
submitted.
UnResolved
REVIEW COMMENTS
Shestak, Joe
From:Huff, Jarrod
Sent:Thursday, March 21, 2024 8:14 AM
To:Jason Whiteley
Cc:Shestak, Joe; Conn, Angelina V
Subject:RE: Whiteley - 560 Cedar Lake Ct - Hamilton County Recorded Easement
Follow Up Flag:Follow up
Flag Status:Completed
Good morning,
Looks good, I will get this onto the next agenda for the Board of Public Works which will be April 3. Please be sure to
send in a check for $28.25 for the recording of the document.
Thank you!
Jarrod Huff, P.E.
Staff Engineer
Engineering Department
One Civic Square
Carmel IN, 46032
Office: 317-571-2441
Direct: 317-571-2309
Email: Jhuff@carmel.in.gov
What's Happening in Carmel?
From: Jason Whiteley <jindy24@gmail.com>
Sent: Wednesday, March 20, 2024 3:41 PM
To: Huff, Jarrod <jhuff@carmel.in.gov>
Cc: Shestak, Joe <jshestak@carmel.in.gov>; Conn, Angelina V <Aconn@carmel.in.gov>
Subject: Re: Whiteley - 560 Cedar Lake Ct - Hamilton County Recorded Easement
Hi Jarrod-
Please see the signed and notarized document you requested attached.
Thank you, Jason
On Mon, Mar 11, 2024 at 11:36 AM Huff, Jarrod <jhuff@carmel.in.gov> wrote:
Good morning,
1
Shestak, Joe
From:Jason Whiteley <jindy24@gmail.com>
Sent:Wednesday, March 20, 2024 3:41 PM
To:Huff, Jarrod
Cc:Shestak, Joe; Conn, Angelina V
Subject:Re: Whiteley - 560 Cedar Lake Ct - Hamilton County Recorded Easement
Attachments:Carmel Eng SignedNotarized Garage Docs 560 Cedar Lake Ct.pdf
Hi Jarrod-
Please see the signed and notarized document you requested attached.
Thank you, Jason
On Mon, Mar 11, 2024 at 11:36 AM Huff, Jarrod <jhuff@carmel.in.gov> wrote:
Good morning,
Jason, I was able to put together the Consent to Encroach last week and was sent out last Wednesday.
It is possible that the automated email was filtered to spam. I have included the document in this email
for you to review, sign, notarize and return to us. The instructions are on the front page but please let me
know if there are any questions.
Jarrod Huff, P.E.
Staff Engineer
Engineering Department
One Civic Square
Carmel IN, 46032
Office: 317-571-2441
Direct: 317-571-2309
Email: Jhuff@carmel.in.gov
What's Happening in Carmel?
1
CONSENT TO ENCROACH
THIS CONSENT TO ENCROACH (hereinafter the "Agreement") is entered into by and between Whiteley, Jason M & Amy
M, 560 Cedar Lake Ct, Carmel, Hamilton County, Indiana 46032, (individually and collectively, "Owner"), and the City of
Carmel, Hamilton County, Indiana, by and through its Board of Public Works and Safety ("City").
WITNESSETH:
WHEREAS, Owner owns in fee simple Lot 11 ("Lot") in CEDAR LAKE, section 1, which is located within the corporate limits of
the City of Carmel, Indiana ("Subdivision"), which real estate is more particularly described in Exhibit A, attached hereto and
incorporated herein by the reference; and
WHEREAS, the official plat of the Subdivision was recorded in PB 12 PG 12-14, Instrument Number 859271 in
the Office of the Hamilton County Recorder on 07/07/1985, as CEDAR LAKE, section 1 (the "Plat"); and
WHEREAS, the current Owner wishes to install a 2 car detached garage on the Lot (the "Site Improvement"); and
WHEREAS, Owner has given the City a sketch ("Sketch") depicting the location of the Site Improvement on the Lot, a
copy of which is attached hereto and incorporated herein by this reference as Exhibit B; and
WHEREAS, the Site Improvement will be constructed on portions of the Lot designated as 25-foot Drainage, Utility
and Sewer Easement, identified as "25' D.U.&S.E." on Exhibit B (the "Easement"); and
WHEREAS, the Easement is beneficial to the City and its residents; and
WHEREAS, as indicated on the Sketch, the Site Improvement will encroach (the "Encroachment") upon the Easement,
which Encroachment is crosshatched on Exhibit B; and
WHEREAS, City of Carmel Board of Public Works and Safety approves the Owner's request for a variance from
Carmel City Code Section 6-227(4); and
WHEREAS, Owner and City acknowledge the location of the Encroachment; and
WHEREAS, Owner acknowledges that this Agreement does not imply any approval of existing or future improvements
not indicated by Owner on Exhibit B. and
WHEREAS, the location of the Site Improvement as indicated by the Owner on Exhibit B should not materially
interfere with the City's use of the Easement
NOW, THEREFORE, for and in consideration of the mutual covenants and agreements contained herein and
other good and valuable consideration, the sufficiency and receipt of which are hereby acknowledged, the
parties mutually promise, agree and covenant as follows:
1. The foregoing preambles, recitations and definitions are made a part hereof as though such were fully
set forth herein.
2. The City consents to the Encroachment for only so long as
(i) the Encroachment exists; and
(ii) Owner complies with all of the terms and provisions of this Agreement.
3. Owner covenants and agrees not to extend, increase, modify, alter, landscape, reconfigure or otherwise
change the Site Improvement from what is depicted on Exhibit B, and to maintain the Site Improvement in
good condition and repair.
4. Owner agrees that City shall have the right to remove any portion of the Site Improvement as City deems
necessary, in City's sole discretion, to install, protect and/or repair any utility lines, sewer lines or drainage
ditches located in the Easement, or for any other lawful purpose, and that, should the City take such action, the
City shall incur no obligation to repair, replace or reimburse Owner for the cost of any damages thereby caused
to the Site Improvment, the Lot, or to Owner
5. Owner agrees and acknowledges that the City's consent to encroach upon the Easement, as provided in this
instrument, regards the City's Easement interests only, and does not constitute permission or authority for the
Owner to otherwise enter on, in, under, over, or upon the property interests of any other person without that
person's consent even if such property interests are also located within the Easement.
6. Owner agrees to indemnify and hold harmless City, its officers, officials, members, employees, invitees,
licensees and agents, from and against any and all losses, liabilities, damages, claims, judgments, attorney fees
and costs arising from any bodily injury and/or death, and from any destruction or damage to any property or
improvements, located on the Lot, or otherwise, and/or for any failure of proper disclosure pursuant to
Paragraph 12 hereof, which results directly or indirectly from any act of Owner, its employees, contractors
and/or agents in, on, under, across or to the Easement.
7. Owner agrees to reimburse City for any and all costs and expenses incurred by City to replace or repair any
damage to the Easement and any improvements located therein caused by the installation, construction,
maintenance and/or operation of the Site Improvement.
8. The parties agree that the terms of this Agreement shall be binding upon and inure to the benefit of their
respective heirs, administrators, successors and assigns.
9. The parties executing this Agreement represent and warrant that they are authorized to enter into and execute
this Agreement for and on behalf of the party which they represent.
10. This Agreement shall be effective as of the date on which it is last executed by a party hereto.
11. The Owner agrees to provide full disclosure of this Agreement to all persons, entities and others who acquire
by or through Owner any interest in the Lot on and after the effective date of this Agreement
12. Owner agrees not to alter the ground surface elevation within the limits of the easement at any time.
13. Owner agrees to remedy any drainage problems or issues, saturated soil or standing water on the Lot or
adjacent properties determined by the City to be resulting from the Encroachment.
"OWNER"
PROPERTY OWNER
��sv� wtd I Tr;
Printed ame
Sig(ature
Date: 1-7-0 2
STATE OF INDIANA )
) SS:
COUNTY OF 161C V106 )
PROPERTY OWNER
Date: T
Before me, a Notary Public in and for said County and State, personally appeared , J Anil ��"H ( L
by me known, and who acknowledged the execution of the foregoing "CONSENT TO ENCROACH' as his or
her voluntary act and deed. (} r
Witness my hand and Notarial Seal this day of r , 20
My Commission Expires:
AMAZA M SMITH
Notary Public, State of Indiana
Z SEAL; Hendricks County
Commission Number NPOS72869
P AN� My Commission Expires
September 13, 2031
"A�, kJ
NOTARY PUBLIC
AY�Ka K-�( a-
Printed Name
My County of Residence:
Engineering Department
Attn: Jarrod Huff
Carmel City Hall
1 Civic Square
Carmel, IN 46032
Consent to Encroach Instructions
l Petitioners (and successors and assigns) agree to remedy any drainage issues resulting from the installation of the
improvement that, in the opinion of the City, represents a Detriment as defined in City Code
Print this document single sided (You do not need to print this instructions page). This is a requirement for
recording. Double sided prints will not be accepted.
Sign on page 3 and have a notary complete the bottom portion of this page.
Please mail or deliver the signed original copy to:
1)
2)
3)
Include a check for $28.25 payable to the City of Carmel for the recording fees. We will record the signed
document for you with Hamilton County after it has been approved.
4)
l
Once we receive the signed agreement and check, I will place the document on our next Board of Public Works meeting
agenda. They will need to give final approval. We will recommend approval to the Board of Public Works with the
following conditions:
Petitioners enter into a Consent-to-Encroach Agreement with the City and record the Agreement (we will
record the agreement for you)
WHEREAS, the official plat of the Subdivision was recorded in PB 12 PG 12-14, Instrument Number 859271 in
the Office of the Hamilton County Recorder on 07/07/1985, as CEDAR LAKE, section 1 (the “Plat”); and
WHEREAS, the current Owner wishes to install a 2 car detached garage on the Lot (the “Site Improvement”); and
WHEREAS, Owner has given the City a sketch (“Sketch”) depicting the location of the Site Improvement on the Lot, a
copy of which is attached hereto and incorporated herein by this reference as Exhibit B; and
WHEREAS, the Site Improvement will be constructed on portions of the Lot designated as 25-foot Drainage, Utility
and Sewer Easement , identified as "25' D.U.&S.E." on Exhibit B (the “Easement”); and
WHEREAS, the Easement is beneficial to the City and its residents; and
WHEREAS, as indicated on the Sketch, the Site Improvement will encroach (the “Encroachment”) upon the Easement,
which Encroachment is crosshatched on Exhibit B; and
WHEREAS, City of Carmel Board of Public Works and Safety approves the Owner’s request for a variance from
Carmel City Code Section 6-227(4); and
WHEREAS, Owner and City acknowledge the location of the Encroachment; and
WHEREAS, Owner acknowledges that this Agreement does not imply any approval of existing or future improvements
not indicated by Owner on Exhibit B; and
WHEREAS, the location of the Site Improvement as indicated by the Owner on Exhibit B should not materially
interfere with the City’s use of the Easement.
CONSENT TO ENCROACH
THIS CONSENT TO ENCROACH (hereinafter the "Agreement") is entered into by and between Whiteley, Jason M & Amy
M, 560 Cedar Lake Ct, Carmel, Hamilton County, Indiana 46032, (individually and collectively, "Owner"), and the City of
Carmel, Hamilton County, Indiana, by and through its Board of Public Works and Safety ("City").
WITNESSETH:
WHEREAS, Owner owns in fee simple Lot 11 ("Lot") in CEDAR LAKE, section 1, which is located within the corporate limits of
the City of Carmel, Indiana ("Subdivision"), which real estate is more particularly described in Exhibit A, attached hereto and
incorporated herein by the reference; and
The parties executing this Agreement represent and warrant that they are authorized to enter into and execute
this Agreement for and on behalf of the party which they represent.
9.
The foregoing preambles, recitations and definitions are made a part hereof as though such were fully
set forth herein.
1.
The City consents to the Encroachment for only so long as
(i) the Encroachment exists; and
(ii) Owner complies with all of the terms and provisions of this Agreement.
NOW, THEREFORE, for and in consideration of the mutual covenants and agreements contained herein and
other good and valuable consideration, the sufficiency and receipt of which are hereby acknowledged, the
parties mutually promise, agree and covenant as follows:
Owner covenants and agrees not to extend, increase, modify, alter, landscape, reconfigure or otherwise
change the Site Improvement from what is depicted on Exhibit B, and to maintain the Site Improvement in
good condition and repair.
2.
3.
4.Owner agrees that City shall have the right to remove any portion of the Site Improvement as City deems
necessary, in City's sole discretion, to install, protect and/or repair any utility lines, sewer lines or drainage
ditches located in the Easement, or for any other lawful purpose, and that, should the City take such action, the
City shall incur no obligation to repair, replace or reimburse Owner for the cost of any damages thereby caused
to the Site Improvment, the Lot, or to Owner
Owner agrees and acknowledges that the City’s consent to encroach upon the Easement, as provided in this
instrument, regards the City’s Easement interests only, and does not constitute permission or authority for the
Owner to otherwise enter on, in, under, over, or upon the property interests of any other person without that
person’s consent even if such property interests are also located within the Easement.
Owner agrees to indemnify and hold harmless City, its officers, officials, members, employees, invitees,
licensees and agents, from and against any and all losses, liabilities, damages, claims, judgments, attorney fees
and costs arising from any bodily injury and/or death, and from any destruction or damage to any property or
improvements, located on the Lot, or otherwise, and/or for any failure of proper disclosure pursuant to
Paragraph 12 hereof, which results directly or indirectly from any act of Owner, its employees, contractors
and/or agents in, on, under, across or to the Easement.
Owner agrees to reimburse City for any and all costs and expenses incurred by City to replace or repair any
damage to the Easement and any improvements located therein caused by the installation, construction,
maintenance and/or operation of the Site Improvement.
The parties agree that the terms of this Agreement shall be binding upon and inure to the benefit of their
respective heirs, administrators, successors and assigns.
5.
6.
7.
8.
This Agreement shall be effective as of the date on which it is last executed by a party hereto.10.
The Owner agrees to provide full disclosure of this Agreement to all persons, entities and others who acquire
by or through Owner any interest in the Lot on and after the effective date of this Agreement.
Owner agrees to remedy any drainage problems or issues, saturated soil or standing water on the Lot or
adjacent properties determined by the City to be resulting from the Encroachment.
Owner agrees not to alter the ground surface elevation within the limits of the easement at any time.
11.
12.
13.
"OWNER"
PROPERTY OWNER PROPERTY OWNER
Printed Name Printed Name
Signature Signature
Date:Date:
STATE OF INDIANA
COUNTY OF
)
) SS:
)
Before me, a Notary Public in and for said County and State, personally appeared
by me known, and who acknowledged the execution of the foregoing "CONSENT TO ENCROACH ' as his or
her voluntary act and deed.
Witness my hand and Notarial Seal this ____ day of ______________________, 20___.
NOTARY PUBLICMy Commission Expires:
Printed Name
My County of Residence:
"CITY"
CITY OF CARMEL, INDIANA,
BY AND THROUGH ITS BOARD OF
PUBLIC WORKS AND SAFETY
BY:
Sue Finkam, Presiding Officer
Laura Campbell, Member
Alan Potasnik, Member Jacob Quinn, Clerk
Date:
Date:
Date:Date:
STATE OF INDIANA
COUNTY OF HAMILTON
)
) SS:
)
Before me, a Notary Public in and for said County and State, personally appeared SUE FINKAM, LAURA
CAMPBELL and ALAN POTASNIK, by me known, and by me known to be the Members of the City of
Carmel Board of Public Works and Safety, and Jacob Quinn, Clerk of THE CITY OF CARMEL, who
acknowledged the execution of the foregoing “CONSENT TO ENCROACH” on behalf of the City of Carmel,
Indiana.
Witness my hand and Notarial Seal this _____ day of ______________, 20__.
NOTARY PUBLICMy Commission Expires:
Printed Name
My County of Residence:
This instrument was prepared by Sergey Grechukhin, Esquire, Transactions Chief, One Civic Square, Carmel,
Indiana 46032.
I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security Number in this
document, unless required by law. Sergey Grechukhin, Esquire
Exhibit A
Shestak, Joe
From:Conn, Angelina V
Sent:Thursday, February 29, 2024 3:36 PM
To:Jason Whiteley
Cc:Shestak, Joe; Huff, Jarrod
Subject:Re: Whiteley - 560 Cedar Lake Ct - Hamilton County Recorded Easement
Attachments:HamCounty Recorded EasementVariance 06132023.pdf
Follow Up Flag:Follow up
Flag Status:Completed
Thank you, Jason. It looks like you had also submitted a Consent to Encroach application via the city's online
application portal. It is case no. CO-2023-0034. I have copied Jarrod Huff with the Carmel Engineering Dept. on
this email, to find out the status of that CTE request for the BPW (Board of Public Works & Safety).
Sincerely,
Angie Conn, AICP | Planning Administrator
Carmel Planning & Zoning Dept. - DOCS
1 Civic Square, Carmel, IN 46032
O: 317-571-2417 | W: carmeldocs.com
From: Jason Whiteley <jindy24@gmail.com>
Sent: Thursday, February 29, 2024 3:23 PM
To: Conn, Angelina V <Aconn@carmel.in.gov>
Cc: Shestak, Joe <jshestak@carmel.in.gov>
Subject: Whiteley - 560 Cedar Lake Ct - Hamilton County Recorded Easement
Hi Angie-
Please see attached drainage easement variance that was approved and recorded on 06/13/2023. I
believe this is the paperwork you are requesting I submit per the approval of the variances earlier this
week.
Thank you, Jason
317-430-9809
1
NON —ENFORCEMENT OF DRAINAGE
EASEMENT ON INDIVIDUAL TRACTS
L G .'ATE OF INDIANA
OCT 17 2022COUNTY OF E AMILTON
2023021513 EASEMENTS $0.00
06/13/2023 03:02:32P 2 PGS
Trini Beaver
HAMILTON County Recorder IN
Recorded as Presented
BEFORE THE HAMILTON
COUNTY DRAINAGE BOARD
oF KAwaoN COU11TY WYEWTIEREAS, Jason M & Amy M Whiteley ("the
Landowner") are owner(s) of a certain parcel of real estate located in Hamilton County, Indiana,
which is commonly known as Hamilton County Tax Parcel No. 16-09-24-01-04-011.000 ` ("the
Real Estate"); and,
WHEREAS, the Real Estate is described in the Deed of the Landowner(s) in Deed
Book _ Page or Instrument No. Cgo 1 OU in the Office of the Hamilton
County Recorder; and,
WHEREAS, the Real Estate is subject to a Drainage Easement for the
14 V V 14trS CI(' oc V i l l CL Drain ("the Drainage Easement") and the Landowner(s),
have requested that the Drainage Boar ("the Drainage Board") waive the right to enforce certain
restrictions within the Drainage Easement.
IT IS THEREBY AGREED by the Drainage Board and the Landowner(s) as follows:
1.) The Drainage Board agrees that the Landowner(s) may construct
24' X 30' Detached 2 Car Garage within the Drainage Easement subject to
submitted Surveyor's Location Report & Plot plan.
2.) In consideration of the consent set out in the above paragraph, the Landowner(s),
on behalf of themselves, successors, and assigns, as Owners of the Real Estate acknowledge that if
necessary, in order to maintain, construct, or reconstruct the drainage improvements in the Drainage
Easement, the Drainage Board, its contractors and workers working under said authority, may
remove all improvements located within the Drainage Easement
3.) In the event of said removal, the Landowner(s), on behalf of themselves, and
successors in title to the Real Estate hereby release and waive any claim that they may have against
the Drainage Board, or any contractor or workmen operating under the authority of the Drainage
Board for the costs or damage to the improvements located within the Drainage Easement.
4.) The Drainage Board agrees not to enforce its easement rights beyond a distance
of 10 _ feet from the East side of the top of bank and/or centerline of the tile within
the Drainage Easement, unless for maintenance or construction described in Section 2 above.
Page I of 2
NZ;- - 0UN& )
Revised May 2016
Adobe PDF Finable Form
-TAN C
NON -ENFORCEMENT OF DRAINAGE
EASEMENT ON INDIVIDUAL TRACTS
Tag Parcel Number 16-09-24-01-04-011.000
Drain Name _
THIS AGREEMENT WILL BECOME EFFECTIVE UPON DRAINAGE BOARD
APPROVAL.
Dated this /1"4- day of aGfP , 20 L- , by the Landowner(s).
LANDO R(s)
By: ' —
Printed:�°�
STATE OF INDIANA
)SS:
COUNTY OF HAMILTON )
20 ��ubscribed and sworn to before me, a No Public this day of
, perso a yr a pe• ed the within named �� ° /i-( li • P and
.fa as Landowner(s) and acknowledged the execution of the
foregoing document. "7
WITNESS my hand and official seal.
My Commission Expires:
BRADLEY M. MOSS
Notary Public - Sea!
Harniltun County - State of Indiana
Commission Number NP0678924
My Commission Expires Mar 22, 2024
Notary Public,
Residing in
County, IN
Dated this - a t day of J ��p _ _ 20_,RL3_, by the Hamilton County Drainage Board.
ATTEST:
y e Mosba gh, Secretary
HAMILTON COUNTY DRAINAGE BOARD
"ident
r0Y
Mark Heirbrandt
"I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security
Number in this document, unless required by Iaw: Kenton C. Ward, Survaor "
Prepared by the Hamilton County Drainage Board: Michael A. Howard Attorney
Page 2 of 2 Revised May 2016
Adobe PDF Flllable Form