HomeMy WebLinkAboutApplication APPLICANT 4/1/2022City of Springfield
Development & Public Works
225 Fifth Street
Springfield, OR 97477
Minimum Development Standards (Major)
SPRINGFIELD
W 0#1
Required Project Information (Applicant: complete this section)
Applicant Name: Amanda Steffanic Phone: 509-867-7786 x114
Company: Wenspok Companies E-mail: amanda@wenspok.com
Address: 9503 E. Montgomery Ave. Floor 1, Spokane Valley, WA 99206
Applicant's Rep.: Robin Ersfeldt
Phone: 630-375-1800
Company: Watermark Engineering Resources, Ltd.
E -mall: rersteldt@watermark-engined ng zoi
Address: 2631 Ginger Woods Parkway, Suite 100, Aurora, IL 60502
Property Owner: 1950 Mohawk, LLC
Phone: 541-998-2388
Company: See above
E-mail: kstraube@darimart.com
Address: 125 E. 6th Avenue. Junction City, OR 97448
ASSESSOR'S MAP NO:
TAX LOT NOS : 1703252405500
Property Address: 1930 Mohawk Boulevard
Size of Property: 1.39 total lot size, disturbed area = 0.64 Acres ® Square Feet ❑
Description of Demolish existing Izzy's Building and put anew Wendy's with Drive-Thru and parking in its place.
Proposal:
Existing Use: Restaurant
Si natures: Please si n and print your name and date in the appropriate box on the next a e.
Required Property Information (City Intake Staff., complete this section)
Associated Cases:
Case No.:
Date:
Reviewed by:
Application Fee: $
Technical Fee: $
Posta a Fee: $0
TOTAL FEES: $
PROJECT NUMBER:
Revised 5/21/13 KL 1 of 9
Signatures
Applicant:
The undersigned acknowledges that the information in this application is correct and accurate.
Rosh E Date: 3/23/2022
Signature
Robin Ersfeldt
If the app !cant is n owner, the owner hereby grants permission for the applicant to ct In his/her behalf.
Owner:
Date: 3 i 2Z
Si nature
Print
Revlaed 5/21/13 KL 2 of
Minimum Development Standards Application Process
As stated in SDC 5.15-100, the minimum development standards (MDS) process is intended to support
economic development by minimizing City review for minor additions, expansions, or changes in use as
specified in SDC 5.15-100. MDS ensures that such development, however, complies with specific
appearance, transportation, safety and efficiency, and stormwater management standards specified in the
SDC and otherwise protects the public health, safety and welfare.
1. Applicant Submits a Minimum Development Standards Application to the
Development & Public Works Department
The application must conform to the Minimum Development Standards Submittal
Requirements Checklist on pages 4-5 of this application packet.
Planning Division staff screen the submittal at the front counter to determine
whether all required items listed in the Minimum Development Standards Submittal
Requirements Checklist have been submitted.
Applications missing required items will not be accepted for submittal
2. City Staff Conduct Detailed Completeness Check
• Planning Division staff conducts a detailed completeness check within 30 days of
submittal.
• The assigned Planner notifies the applicant in writing regarding the completeness of
the application.
• An application is not be deemed technically complete until all information necessary
to evaluate the proposed development, its impacts, and its compliance with the
provisions of the Springfield Development Code and other applicable codes and
statutes have been provided.
• Incomplete applications, as well as insufficient or unclear data, will delay the
application review process and may result in denial.
3. City Staff Review the Application and Issue a Decision
• This is a Type I decision and thus is made without public notice and without a public
hearing since there are clear and objective approval criteria and/or development
standards that do not require the use of discretion.
• Decisions address all the applicable approval criteria and/or development standards.
• Applications may be approved, approved with conditions, or denied.
• The City mails the applicant and any party of standing a copy of the decision, which
is effective on the day it is mailed.
The decision issued is the final decision of the City and may not be appealed.
Revised 5/21/13 KL 3 of 9
Minimum Development Standards Submittal Requirements Checklist
NOTE: If you feel an item does not apply, please state the reason why and attach the
explanation to this form.
Application Fee - refer to the Development Code Fee Schedule for the appropriate fee
calculation formula. A copy of the fee schedule is available at the Development & Public
Works Department. Any applicable application, technology, and postage fees are collected
at the pre -submittal and submittal stages.
Minimum Development Standards Major Application Form
Copy of the Deed
❑ State or Federal Permits Required - The applicant must demonstrate that an
application has been submitted for any required federal or state permit and provide a
copy of the application upon request. Not applicable. There is no work being proposed in the
state or federal jurisdictions.
Narrative explaining the purpose of the proposed development, the existing use of the
property, and any additional information that may have a bearing in determining the
action to be taken. The narrative should also explain justification for proposed MDS
exceptions and should also include other activities proposed on the property such as tree
removal, grading, fill or excavation. A description of the proposed use and explanation of
the uses conducted in building areas and the square footage of each area.
Storm water Scoping Sheet
Four (4) Copies of the following Plan Sheets:
MDS Site Assessment of Existing Conditions meeting the following standards:
❑ The plan shall be drawn by a licensed engineer, architect, landscape architect or land
surveyor.
❑ The plan shall provide the name location and dimensions of all existing site features
including, but not limited to significant stands of trees and watercourses shown on the
Water Quality Limited Watercourse Map and their riparian areas, wetlands, flood
designations and slopes.
MDS Site Plan, prepared by a licensed engineer, architect, landscape architect or
land surveyor, incorporating the following standards:
❑ Proposed Building Envelopes
❑ Dimensions of the Development Area
❑ Where applicable, Location of Existing, Planned or Proposed Transit
Facilities*
❑ Area of all Property to be Reserved, Conveyed or Dedicated.
Revised 5/21/13 KL 4 of 9
❑ A S -Foot Wide Landscape Planter Strip including:
• Property lines, setbacks and dimensioned landscape areas
• Street trees location and type, landscaping and irrigation*
• Fencing
• Percentage of Landscape Coverage
• Planting List*
*Property lines, setbacks and dimensioned landscape areas shall be shown on all
applications; however street trees, fencing and planting information may be noted and
details deferred to Final MDS Plan Approval or Building Permit Submittal.
❑ Trash Receptacle Enclosure and Outdoor Storage Areas including:
• Screening and Cover*
• Connected to sanitary sewer as applicable
• Required Screening for outdoor storage areas*
*Materials and construction types shall be noted and details may be deferred until
Final MDS Approval or Building Permit Submittal.
❑ Bicycle Parking Spaces including:
• Number and location
• Type of bike rack*
*Long term and short term bicycle parking shall be noted and details may be deferred to
Final MDS Approval or Building Permit Submittal.
❑ Parking and circulation areas including:
• Location, dimension number and striping of typical, compact and disabled
parking spaces including aisles
• Wheel stops as required
• On-site loading areas and vehicular and pedestrian circulation
• Storm water management provisions (existing or proposed catch basins, existing
or proposed bioswales)
❑ Access to the Public Right -of -Way including:
• Location and dimensions of existing and proposed curb cuts and any curb cuts to
be closed.
Revised 5/21/13 KL 5 of 9
❑ Concrete Sidewalks including:
• Existing sidewalks
• Proposed sidewalks where development abuts a curb and gutter street
❑ Streetlight Locations
0 An Improvement and Public Utilities Plan meeting the following standards:
❑ Prepared by a licensed engineer where utility systems are proposed
❑ Location and width of existing and proposed easements
❑ Location and dimensions of all existing and proposed rights of way
❑ Location of existing and proposed utilities and infrastructure on or adjacent
to the subject site including the following as applicable: storm water
management systems, sanitary sewer mains, power, water mains, gas,
telephone and cable connections.
❑ Drainage patterns and connection points with supporting documentation
to demonstrate the proposed system will function consistent with the
City of Springfield Engineering Design Standards and Procedures Manual.
*The applicant may request deferral of plan details demonstrating compliance with standards of
SDC 5.15-120 until Final MDS Plan Submittal, building permit submittal or building permit
Occupancy as noted herein.
Revised 5/21/13 KL 6 of 9
l r i�Lj la
�S14t5�
U RETURN TO CASCADE TITLE CO.
0). "jh
After recording, return to:
1950 Mohawk, LLC
668 Greenwood
Junction City, Oregon 97448
Until a change is requested,
mail all tax statements to:
1950 Mohawk, LLC
668 Greenwood
Junction City, Oregon 97448
Tax Account Number: 0206191
Division of Chief Deputy Clerk
Lane County Deeds and Records
iiiiiiiiiiiii
00736768200800731220040044
RPR -DEED
Cnt=1
Stn=5
$20.00
$11.01
$10.00
STATUTORY WARRANTY DEED
2005.0]3122
0911612005 10,1121,32 RM
CASHIER 04
Gramzow & Sons Land and Cattle Company, LLC, an Oregon limited liability company,
Grantor, conveys and warrants to 1950 Mohawk, LLC, an Oregon limited liability company,
Grantee, the real property described on the attached Exhibit A free of encumbrances except as
specifically set forth on Exhibit A.
The true consideration for this conveyance is Two Million Three Hundred Tbousand
Dollars ($2,300,000.00),,
THIS INSTRUMENT WILL NOT ALLOW USE OF THE PROPERTY DESCRIBED
IN THIS INSTRUMENT IN VIOLATION OF APPLICABLE LAND USE LAWS AND
REGULA'T'IONS. BEFORE SIGNING OR. ACCEPTING TRIS INSTRUMENT, THE
PERSON ACQUIRING FEE TITLE TO THE PROPERTY SHOULD CHECK WITH THE
APPROPRIATE CITY OR COUNTY PLANNING DEPARTMENT TO VERIFY APPROVED
USES AND TO DETERMINE ANY LIMITS ON LAWSUITS AGAINST FARMING OR
FOREST PRACTICES AS DEFINED IN ORS 30.9301,
DATED: September 15, 2005.
GRAMZOW & SONS LAND AND CATTLE
COMPANY, LI,,C _
By:
MaffiCew J. �Gtamzow, Managing Member
Page I —STATUTORY WARRANTY DEED
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STATE OF OREGON
COUNTY OF LANE
This instrument was acknowledged before me on September 4.� , 2005) by Matthew J.
Gramzow, Managing Member of Gramzow & Sons Land and Cattle Company, LLC.
Ap
OrFICIAL SEAL
SARAH J VA1
NOTARY PUBLIC - OREGON
COMMISSION NO. 374103
MY COMMISSION EXPIRES JANUARY 7, 2X08
Mary Pub 'c for egon
My comma expires:
Page2—STATUTORY WARRANTY DEED
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PROPERTY DESCRIPTION
Beginning at a point on the Westerly right of way line of 19th Street North 88' 13'
051+ West 45.0 feet from a point on the centerline, said point being South 01' 46' 55"
West 92.0 feet from the Southwest corner of the Felix Scott Donation Land Claim No.
51, Township 17 South, Range 3 West of the Willamette Meridian; thence South 01' 46'
55" west along said Westerly right of way line 105.67 feet to a point; thence along
the arc of a 671.20 foot radius curve right (the chord of which bears South 08' 05'
3911 West 147.59 feet) 147.89 feet to a point on the Northerly right of way line of I--
105; thence along said Northerly right of way line the following five courses and
distances: 1) South 47' 35' 05" West 25.88 feet, 2) South 30' 53' 05" West 30.75
feet, 3) North 88' 06' 55" West 100.55 feet, 4) South 61' 56' 341' West 78.55 feet, 5)
North 884 06' 05" nest 35.04 feet to the Easterly right of way line of the 19th Street
connector; thence along the said Easterly right of way line the following six courses
and distances: 1 ) along the arc of a 348.31 foot radius curve left (chord = North 18
10' 33" East 32.73 feet) 32.74 feet, 2) North 15' 28, 58" East 150.96 feet, 3) along
the arc of a 288.31 foot radius curve right (chord = North 23' 55' 40" East 84.68 -
feet) 84.99 feet , 4) along the arc of a 288.31 foot radius curve right (chord = North
32' 33' 34" East. 1.87 feet) 1.87 feet, 5) along the arc of the 288.31 foot radius
curve right (chord = North 50` 02' 50" East 171.48 feet) 174,12 feet, 6) South 51' 01,
29" East 59.83 feet, to the point of beginning, in Springfield, Lane County, Oregon,
all being in Section 25, Township 17 South, Range 3 West of the Willamette Meridian,
in Dane County, Oregon.
The bearings in this description are based on the Oregon State Grid Coordinate System,
South Zone.
Subject to:
1. Taxes for the fiscal year 2005-2006, a lien not yet payable.
2, Reservation of one-half of the oil, gas and other hydrocarbons and
minerals, including the terms and provisions thereof, in deed from The
Union central Life Insurance Company, recorded June 27, 1944, in Book
269, Page 651, Lane county Oregon Beed Records.
.�
3. Access restrictions, including the terms and provisions thereof, in deed to
State of Oregon, by and through its State Highway Commission, recorded
March 19, 1962, Reception No. 62942, Lane County official Records.
4. Access restrictions, including the terms and provisions thereof, in deed to
Lane county, recorded July 19, 1971, Reception No. 55517, Lane county
Official Records,
5. Agreement including the terms and provisions thereof, between DeWayne
Wafford and the City of Springfield, recorded March 2, 1984, Reception
No. 84083091, Lane County official Records.
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6. Notice of intent to preserve mineral rights, including the terms and
provisions thereof, recorded December 20, 2002, Reception No. 2002-
099255, Lane County Deeds and Records.
7. The rights of tenants -in -possession.
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Wendy's -Springfield, Oregon Narrative
The existing site to be developed is a 0.64 -acre portion of an overall lot that is 1.39 acres in size. The
0.64 -acre portion that is being developed currently consists of an Izzy's Restaurant with parking. The
area to be developed is adjacent to a Dari Mart Convenient Store to the North that is part of the 1.39 -
acre lot. The site is bordered by Mohawk Boulevard to the East and Q Street to the West, and already
has access onto both streets as part of the overall and already existing development. The property is
currently zoned Community Commercial. The area to the south of this site is ODOT property that was
previously being leased to use for parking. As part of this development, that lease will no longer be in
place and those parking spaces will no longer be utilized.
The proposed use for the site is a Wendy's Restaurant with Drive-Thru and parking. The building is
approximately 2,456 S.F. in size. This type of use is allowed within the existing zoning regulations and no
re -zoning will be required for this development. The proposed site works within the existing curbed
envelope for the existing parking lot, therefore keeping the buffer yards the same as in the existing
condition. The existing traffic patterns for the overall retail center will be maintained, while providing
one way circulation internally for the Wendy's site (which is typical of Wendy's drive-thru layouts). The
Wendy's will utilize the existing access off of both Mohawk Boulevard and QStreet in order to enter and
exit the site. The site will provide a connection to the existing public sidewalk along Mohawk Boulevard.
A proposed pole sign to identify the Wendy's is being proposed in the same location as the existing
signage for the Izzy's Restaurant.
The site is provided with utilities in order to serve this use. Stormwater will be collected in area drains
on the pavement as in the existing condition and the on-site storm sewer system will connect into the
existing system on the West side of Mohawk Boulevard. The water connection to serve this building will
be made to a main located on the East side of Q Street. The sanitary sewer will connect to an existing B"
stub located within the existing parking lot of the Dari Mart/Izzy's site.
225 FIFTH STREET
SPRINGFIELD, OR 97477
PHONE: 541.726.3753
FAX. 541.736.1021
www.spnngfield-orgov
December 6, 2013
REQUIRED STORMWATER SCOPING SHEET USE POLICY:
In October 2003, Springfield Public Works released a trial "stonnwater scoping sheet," provided to help
engineers and developers meet stormwater requirements in the Springfield Development Code (SDC) and
Engineering Design Standards and Procedures Manual (EDSPM). After a five month trial period, it became
apparent that users of the scoping sheet submitted much more complete applications than non-users. An added
bonus was a decrease in the overall review time spent on the applications, resulting in quicker notice of
decisions.
As a result of the benefits of the scoping sheets, the City has decided to make their use a mandatory process.
Current city policy is that the use of stormwater scoping sheets is required for all applications which require
development review. All applications submitted to the City shall provide a copy of a completed stormwater
scoping sheet with the application packet. Attached with this letter is the latest version of the scoping sheet,
which reflects changes requested by the development community.
PLEASE NOTE: SUBMITTED APPLICATIONS WILL NOW BE REQUIRED TO SUBMIT A
COMPLETED STORMWATER SCOPING SHEET, STORMWATER STUDY AND PLANS IN
CONFORMANCE WITH THE SCOPE REQUIREMENTS
U 17 rrrrr 31b4LCeI91 ri7 V,P"IN N:1
1.) Obtain scoping sheet from application packet, city website, or other location.
2.) Fill out project information (top half of front sheet) prior to commencement of work on stormwater study.
(Note: Do not sign scoping sheet until it is received from the City with requirements checked.)
3.) Mail, fax, or email all pages to: City of Springfield, Development and Public Works Dept., Attu: Clayton
McEachem.
4.) Receive completed scoping sheet (filled out by the City) indicating minimum requirements for a complete
stormwater study.
5.) Include four (4) copies of complete scoping sheet (signed by engineer at the bottom of page 2), stormwater
study and plans that comply with the minimum required scope with submittal of application packet. The
scoping sheet shall be included as an attachment, inside the front cover of the stormwater study.
Stormwater scoping sheets can be found with all application packets (City website and the DPW front counter)
as well as on the Engineering and Construction Resources webpage located at: httv://www.springfield-
or.gov/DPW/EnginmringmdConstructionResources.htm under the Public Improvement Permit Projects Forms
section. Thank you in advance for working with the City of Springfield with this new process.
Sincerely,
Clayton McEachern, PE
City of Springfield, Development and Public Works
Email: cmeeachem@springfieldor.gov
Phone: (541) 736 —1036
Fax: (541) 736-1021
DEVELOPMENT AND PUBLIC WORKS
SPRINGFIELD
225 FIFTH STREET
OREGON SPRINGFIELD, OR 97477
PHONE: 541.726.3753
FAX: 541.726.1021
www.spdrygfialdor.gov
STORMWATER MANAGEMENT SYSTEM SCOPE OF WORK
----------- — (Area helm tlds b'neJUIed outbyApplica n) __—
(Please return to Clayton MEachern @ City ofSprb4gi2eld Development and Public Works, Fan # 736-1021, Phone # 736-1036),
enwd:cnae�lern@sprirtglleldor.gov
P,�i,&Narne Wendv's-Sorinafield Ann1w.t 1950 Mohawk. LLC
Assessors Parcel #: 1703252405500 Date: 3/23/2022
LandUse(s): Drive-Thru Restaurant Phone #: 541-998-2388
Project Size (Acres): 0.64 Fax #: N/A
Approx. Impervious Area: 0.59 acres Email: kstraube@darimart.Com
Project Description (Include a copy of Assessor's map):
Demolish existing Izzy's restaurant and put a Wendy's Restaurant with drive-thru and parking in
its place.
Drainage Proposal (Public connedion(s), discharge location(s), etc. Attach additional sheet(s) if necessary:
Capture stormwater onsite and outlet into existing storm sewer system on the West side of Mohawk
Boulevard.
Proposed Storrewater Best Management Practices:
On site stormwater collected in area drains and outletting to existing storm sewer system as in
existing condition. Inlet protection to be provided per the plans for both existing and proposed inlets.
(Area below this line rdkd ord by the City andRehvned k the Aaaheand
(At a nunimmte5 all boxes checked by to City on the front and backoftlds sheet shall be subnutted
or on application to be coaWletefor subnuttal, although oder requirements nay, be recess
Drainage Study Type (EDSPM Section 4.03.2): (Note, UH may be substituted for Rational Method)
❑ Small Site Study—(use Rational Method for calculations)
❑ Mid -Level Development Study— (use Unit Hydrograph Method for calculations)
❑ Full Drainage Development Study— (use Unit Hydrograph Method for calculations)
Environmental Considerations:
❑ Wellhead Zone:
❑ Wedand/Riparian:
❑ Soil Type:
Downstream Analysis:
❑ N/A
❑ Flow line for starting water surface elevation:
❑ Design HGL to use for starting water surface elevation:
❑ Manhole/Junction to take analysis to:
❑ Hillside Development:
❑ Floodway/Floodplain:
❑ Other Jurisdictions
Return to Clayton McEachem @ City of Springfield, email: cmceachem@springfeAd-or,gov, FAX: (541) 736-1021
COMPLETE STUDY ITEMS
r Baredupon the tnfor nation provided on tie front ofdds sheet, the follou>ing represents a ndndnnou of uvh w it merkdfor on
application to be complete for subnddal with respect to drainage; however, this list should not be used in lieu ofde Sprirgtield
Development Cork (SDC) or the City's Engineering Design A3mma1. Connpltance with these requirements does not constitute site
appromol, Adebooml site specific information nary be required Note: Upon scoping sheet subndttal, ensure completedfornu has been
signed in the spare provickel below:
Interim Design Standards/Water Quality (EDSPM Chapter 3
Req'd N/A
❑ ❑ All non -building rooftop (NBR) impervious surfaces shall be pre-treated (e. g. multi-chambered catchbasin w/oil filtration
media) for stonmvater quality. Additionally, aminimum of 50% of the NBR impervious surface shall be treated by
vegetated methods.
❑ ❑ Where required, vegetative stommwater design shall be consistent with design standards (EDSPM Section 3.02), set forth
in Chapter 2 of the Eugene Stormrmer Management Manual.
❑ ❑ For new NBR impervious area less than 15,000 square feet, a simplified design approach may be followed as specified
by the Eugene Stomrmvater Management Manual (Sec2A.1).
❑ ❑ If a stormrmer treatment Swale is proposed, submit calculations/specifications for sizing, velocity, flow, side slopes,
bottom slope, and seed mix consistent with City of Springfield or Eugene's Stomrmvater Management Manual.
❑ Water Quality calculations as required in Section 3.03.1 of the EDSPM.
All building rooftop mounted equipment, or other fluid containing equipment located outside of the building, shall
be provided with secondary containment or weather resistant enclosure.
❑ n Design of Stoma Systems (EDSPM Section 4.04).
❑ ❑ Flow lines, slopes, rim elevations, pipe type and sizes clearly indicated on the plan set
❑ ❑ Minimum pipe cover shall be 15 inches for reinforced pipe and 36 inches for plain concrete and plastic pipe materials, or
proper engineering calculations shall be provided when less. The cover shall be sufficient to support an 50,000 lb load
without failure of the pipe structure.
❑ ❑ Manning's "n" values for pipes shall be consistent with Table 4-1 of the EDSP. All stoma pipes shall be designed to
Other/Miscethmeous
❑
Drainage study prepared by a Professional Civil Engineer licensed in the state of Oregon.
Existing and proposed contours, located at one foot interval. Include spot elevations and site grades showing how site
❑
A complete drainage study, as required in EDSPM Section 4.03.1, including a hydrological study map.
drains.
❑
Calculations showing system capacity for a 2 -year stoma event and overflow effects of a 25 -year stoma event
Private stommwater easements shall be clearly depicted on plans when private stommater flows from one property to
The time of concentration (Tc) shall be determined using a 10 minute start time for developed basins.
Review ofDownstream System EDSPM Section 4.03A.0
❑
A downstream drainage analysis as described in EDSPM Section 4.03A.C. On-site drainage shall be governed by the
Oregon Plumbing Specialty Code (OPSC).
❑
❑
Elevations of the HGL and flow lines for both city and private systems where applicable.
❑ n Design of Stoma Systems (EDSPM Section 4.04).
❑ ❑ Flow lines, slopes, rim elevations, pipe type and sizes clearly indicated on the plan set
❑ ❑ Minimum pipe cover shall be 15 inches for reinforced pipe and 36 inches for plain concrete and plastic pipe materials, or
proper engineering calculations shall be provided when less. The cover shall be sufficient to support an 50,000 lb load
without failure of the pipe structure.
❑ ❑ Manning's "n" values for pipes shall be consistent with Table 4-1 of the EDSP. All stoma pipes shall be designed to
Other/Miscethmeous
❑
Existing and proposed contours, located at one foot interval. Include spot elevations and site grades showing how site
drains.
❑
Private stommwater easements shall be clearly depicted on plans when private stommater flows from one property to
another.
❑
Drywells shall not receive runoff from any surface w/o being treated by one or more BMPs, with the exception of
residential building roofs (EDSP Section 3.03A A). Additional provisions apply to this as required by the DEQ. Refer to
thewebsite: him/Avww.deo.state.or.ushvo/uic/uic.htm for more infomuation.
❑
Detention ponds shall be designed to limit runoff to pre -development rates for the 2 through 25 -year storm events.
*Thisform simU be inchukd m nn Nhuhmen5 inside the frontcover, ofthe stormnsder shady.
* IAWORTANT..- ENGINEER PLEASE READ BEEOWAND SIGN'
As the engineer of record, I hereby certify the above required items are complete and included with the submitted stommater study
and plan set. Signature Date
Form Version 5: June 2015