HomeMy WebLinkAboutApplication APPLICANT 11/17/2009
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Springfield,OR97477 . ,,' "
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TEMPORARY 1JSE~,l;m~rgericy Medical Hardship, Type II
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ApplicanttN",ille: '
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Property Owner:
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o Residential Trailer
o RV
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Specific Description of Propo~al:' 1'I/(Ptx7t'n9 fm,'/r-r t'" &:ui y::>--rd 0(1
.>o/d fr~I!,~r(Y;/i..{i!It".'vf"''l W/lt;, hc<,.ds!t/~ as Ii!'/ft!'ni-- /11 I-m/k".
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Original Submittal
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Date, Received: ,
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A COMPLETE APPLICATION CONSISTS OF: Original '~ybmittal-C !,
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-1. A complete application page (all of the sections on the first page of this form must be filled out).
~ ~Copies of a plot plan, drawn to scale, showing:' ': , ,
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THE APPLICATION PACKET
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Existing structures on the lot/parcel and their setbacks from property lines;'
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The proposed location of the temporary living quarters and its setback from property lines arid other
structures on the lot/parcel' " '" ;., "":'" ,f~,,, '; " "
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The required utility connections for the temporary living quarters; and
The location of proposed fences to screen the temporary living quarters that face public rights-of-way.
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For those applications within the city's urban service area, the plot plan sh~1I also show'the.lociltion of
, any wells, septic tanks"and.drain fields, , , . ' .)"'" .:: ',' ij',\t~. ;~,
A written medIcal report from a hcensed phYSIcian on offiCIal letterhead that mc\udes: ,'" ,
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The nature of the patient's medical condition and whether the patient in terminally ill or recuperating
from an illness, surgery or;
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A statement explaining why the patient is not physically or mentally capable of self-maint~han~.e and is,
therefore. dependent upon a care provider being on-pite for assistance; and ' : "
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Additional supporting documentation from other medical practitioners who:may be treating the patient,
when applicable, ," "
A statement from the applicant addressing:
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Whether the person requiring medical assistance or the care provider will r~side in,the t~mporary living
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The type of temporary living quarters proposed, wither, a motor home, resi~eritialtraj\er;;',.;trliv~r:, "
trailer, truck camper or other RV as defined in Article 2 of this Code,uri.le~s;'~xcepied.,iKi!li~'section;
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Proof that the temporary living qua~ers is licensed and insured; arid
A statement explaining why the circumstances are temporary in nature iest\.;n~t~..a.t)~ tponths or less)
and what steps are being undel1aken to address the circumstances prior to the'elapsinK qL\:t,tpo_oths" or
any extension thereof.' ~,;: \~ ~.:i.:.i\;': -- }'.'
/ A copy of the deed to show ownership ~" d~i,;?!:>:i:;;':::~4)i:'1tq;i:.'
6. The application fee, Refer to the Development Code Fee Schedulefor thf,appropriat,ifee. A copy of the Fee
Schedule is available at the Development Services Department " '. ,
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5-8-2007 Blones
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Crowson, Thelma
Visit Date: 11/13/2009
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Patient Brief Progress Note
Williamette Valley Psychiatric Medicine, LLC
132 East Broadway, Suite 825 Eugene, OR 97401
Phone: (541) 344-5363 Fax: (541) 344-5369
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DOB: 11/18/1956
Professional: Dr Elaine A Mitchell, DO
Data Entry By: Dr Elaine A Mitchell, DO .
Date{Time Stamp: 11/13/2009 6:27:08 PM
Updated History: November 13 2009
To Whom It May Concern,
Thelma Crowson is a patient of mine and requires round the clock care by her family.
Elaine A. Mitchell D.O.
Date:
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Date Received:
NOV f 7 2009
Original Submitial
Printed 11113/20096:27:09 PM
Page 1 of 1
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Date Received:
NOV 1 7 2009
Original Submittal
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Bargain and Sale Deed
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" "\kNow"jAix MflI BY THESE PRESENTS, That STEVE HARTSOCK AND JULIE HARTSOCK,
, HUSB~.', ~ ~~E, hereinafter called Grantor, for the consider~tion hereinafter stated, does hereby
grant;'baigain; 'sell'-and convey to STEVEN DALE HARTSOCK, TRUSTEE OF THE STEVEN DALE
HARTSOCK REVOCABLE TRUST AND JULIE. MARIE N, HARTSOCK, TRUSTEE OF THE
JULIE-MARIE N. ~TSO<:K REVOCABLE TRUST, bereinafter called Grantee, and unto Grantees'
heirs, successors and. assigns, all' of that certain real property situated in the County of Lane, State of Oregon,
described as follo":s;'ib'w;t:';'
'Ji;.:F;\.~:~;i;'~j'''':i;1'if:~EE LEGAL DESCRIPTION AS ATTACHED EXHIBIT A
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,To h~~~.:~d"t~~;'h6id'?tb,"b same unto the said Grantee and Grantee's heirs, successors and assigns forever, The
true and actual consideration paid for this transfer, stated in terms of dollars is to correct vesting.
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THIS INSTRUMENT WILL NOT ALLOW USE OF THE PROPERTY DESCRIBED IN THIS INSTRUMENT IN
VlOLATlON OF APPLICABLE LAND USE LAWS AND REGULATIONS. BEFORE SIGNING OR ACCEPTING THIS
INSTRUMENT, THE' PERSON ACQUIRING FEE TITLE TO THE PROPERTY SHOULD CHECK WITH THE
APPROPRIATE CITY 'OF COUNTY PLANNING DEPARTMENT TO VEIUFY APPROVED USES AND TO
'DETERMINE ANY LIMiTs ON LAWSUITS AGAINST FARMING OR FOREST PRACTICES AS DEFINED IN ORS
'30.930. , '
;t ~;tne;'s Whereof, the Grantor has executed this instrument this I ,lJay oKJ;u"::j' rYOC/1
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STATEOFOREGONr:(County of Lane) ss,
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iIbis instrument was acknowledged before me on
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IOSEPH M SILENCl!
i~, -! NOTARY PUBUc.OREGON
\.. ......- COMMISSION NO. 343143
. MYCOMMISSll)1 EXP1RES mRlWIY 19, m
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Grantor's Name and Address:
Steve Hartsock And Julie Hartsock
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~ranteels Name and Address:
Steven Dale Hartsock And Julie.Marie N. Hartsock
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Send ,Tax Statements to:
No change requested
11111111111111111111111111111111111111111 11111 III
00~47141200400114680040043
02/20/2004 10:29:15 ~
RPR-OEEO Cnl:l Sln:~ CASHIER 08
S20.00 $11.00 $10.00
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Division 0' Chief Deputy Clerk
Lane Counly Deeds and Recorda
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$41.00
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Date Received:
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NOV 1 7 2009
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Original Submittal
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PAGE IOF 3" ;;{ \'
LEGAL DESCRIPTION
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~. ~gi~rig 42 feet North of the Southwest corner of the North half of Lot 9 in Block 2 in
. ""SHEL1'QN'S.AJ)DITION TO THE TOWN OF EUGENE CITY, Lane County, Oregon, as
platiedandrecOf~~d,;at Page 603 of Volume R, Lane County Oregon Deed Records; thence
North 58.2 feet to the Northwest corner of Lot 10, in Block 2; thence East 85 feet; thence South
58.2 feet to a point 42 feet North of the South line of the North half of aforesaid Lot 9; thence
West 85 feet to the.pi~ce of Beginning, in Lane County, Oregon,
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" . EXCEP.1' THEREFROM the East 6 feet.
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PROPERTY 2: '," .:
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Lot 7, Block 6, PEARL ADDITION ,TO EUGENE, as platted and recorded in Book 5, Page 24,
Lane County Oregon Plat Records, in Lane County, Oregon.
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PROPERTY 3: .
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Lot 13, Block 5, SECOND ADDITION TO NICHOLAS GARDENS, as platted andrecorded
in Book 12, Pa'ge 11;Lane County Oregon Plat Records, in Lane County, Oregon.
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PROPERTY 4: /;;;':1 : y; ~ i.
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ThecWest 45 feet of the following described premises, to-wit: Beginning at a point on the
NorthJinc; of "D"-Street in Springfield, Lane County, Oregon, 60 feet East of the East line of
14t)1,Street;run thence East on the North line of"D" Street 90 feet; thence North 120.97 feet to
the South line oftheJllley running East and West between "D" Street and "E" Street; thence
West on the South line of said alley 90 feet; thence South parallel with the East line of 14th
Street 120.97 feet to the Pla,ce of Beginning, in Lane County, Oregon, both the East and West
boundary lines of said premises being parallel with the East line of said 14th Street, in Lane
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PROPERTY 5:', ,
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TheSouth half of the South half of Lot I] ofHL & TB STEWART'S PLAT, as platted and
recorded in Book 3, Page 5, Lane County Oregon Plat Records, in Lane County, Oregon,
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Date Received:
CONTINUED
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Nav 1 7 2009
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Original Submittal
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EXHIBIT A . .,,,. .
PAGE2 OF 1..,.!i,(~,;;".:,'",...-
. ,LEGAL:r>EscRlPliON .
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P:ROPERTY,6:.;\: .
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Beginning at an iron pipe which is 154.53 feet South of the Northwest comer of Lot 9, of the
HL & TB STEWART'S PLAT, as platted and recorded in Book 3, Page 5, Lane County
Oregon Plat Records; thence East 196.7 feet to an iron pipe; thence South 54.17 feet to an iron
ph).e,~,;;';~eS9.@{ii!ie'ofLot 9 of the HL & TB STEWART'S PLAT; thence West along the
'. S9uth;,JineofLot9;~196.7 feet to an iron pipe; thence North 54.17 feet to the Place of
B~giriill!ig, in Springfield, Lane County, Oregon.
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"EXCEPi':TIIEREFROM the East 8.0 feet conveyed to the City of Springfield, by instrument
Recorded March 3'I/j9~0, Reception No. 95189, Lane County Oregon Deed Records, in Lane
County, Oregon.
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ALSO EXCEPTIl':l'G=' 'Beginning at the Northwest comer of Lot 16 ofHL & TB STEWART'S
PLAT, mj'platted ana recorded in Book 3, Page 5, Lane County Oregon Plat Records; run .
th~nce North 1.67 feet; thence East 196.7 feet; thence South 1.67 feet; thence West 196.7 feet
to~the'Place of Beginning, in Springfield, Lane County, Oregon.
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PROPERTY 7:
Beginning at a poinOl7 feet South of the Northwest comer of Lot 14 in H.L. AND T.E.
STEWART'S PLAT NO. 2 OF ACREAGE LOTS, as platted and recorded in Book 3, Page 36,
Liine !:;otinty Oregon Plat Records; running thence East 188 feet; thence South 52 feet; thence
West 188 feet; thence North 52 feet to the Point of Beginning, all in Springfield, Lane County,
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ALSO: Beginning at a point 117 feet South of the Northeast comer of Lot 14 ofH.L. AND
T.B, STEWART'S PLAT NO. 2 OF ACREAGE LOTS, as platted and recorded in Book 3,
Page 36, Lane County Oregon Plat Records, in Lane County, Oregon; running thence West
20.7feet;.thenceS'outh'52 feet; thence East 20.7 feet; thence North 52 feet to the Point of
~egMning;'in'Springfield, Lane County, Oregon.
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PROPERTY'8:"~ 'e,'
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Lot 6, TEMPE SUBDIVISION, as platted and recorded in Book 35, Page 21, Lane County
Oregon Plat Records;. in Springfield, Lane County, Oregon,
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Date Received:
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CONTINUED
NOV I 7 2009
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Original Submittal
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EXHIBIT A
PAGE 3 OF3 . .P"
u'LEGAi>OESCRIPTIOk
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PR()PERTY9; ,.>,...",
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Beginning at a point,in the North line of"C" Street in Springfield, Lane County, Oregon, 461
feet East of the EastJine of-! O'h Street; run thence East 49 feet; thence North 120 feet to the
South,line, ofthe:ful~yi1inning East and West between "C" and "D" Streets; thence West along
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silidalley 49 feet; tJience South 120 feet to the Point of Beginning, in Lane County, Oregon,
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"PRdpERTY:I0:\~,;~
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All of Lots 15 and 16, Block 70, PLAT OF WASHBURN'S SUBDIVISION OF THE
SPRINGFIELD INVESTMENT AND POWER COMPANY'S ADDITION TO
SPRINGFIELD,as,i!latted and recorded in Book 2, Page 73, Lane County Oregon Plat
~~~~~F:ihi'L~e~C~~ty, Oregon. .
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PROPERTY. 11:
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Lots 7 and 8, Block I, Replat of Lot 22, CLARK AND WASHBURNE'S ADDITION TO
SPRINGFIELD, as platted and recorded in Book 4, Page 3, Lane County Oregon Plat Records,
in Lan~ ,Qounty, Oregon.
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PROPERTY 12:
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The North 73''feefbfLot 7 and the North 73 feet of the North 83 feet of Lot 8, Block 1 of the
illGH SCHOOL ADDITION TO SPRINGFIELD, in Lane County, Oregon,
PROPERTY l3it :tl; ,
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Lbt:l;Block 1, NORTHGATE ADDITION, as platted and recorded in Book 18, Page 1, Lane
! C~Uniy Oregon Plat Records, in Lane County, Oregon.
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Date Received:
NOV 1 7 2009
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Original Submittal
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Date Received:
NOV 1 7 2009
Original Submittal
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Account Number:
Statement Date:
1 of 2
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lo-31~2009
ROBERT W CROWSON
1434 D ST
SPRINGFIELD OR 97477
Statement Summary
Account Number Type
- Regular Share Account
Net Checking
Account Summary for Regular Share Account - ~.-
Starting Dividend
Balance + Deposits + Paid Withdrawals
5.00 0.00 0.00 0.00
Service
Charges
0.00
Balance
5.00
3.31
Ending
Balance
5.00
There is no activity for this account.
The amount of Dividend earned between 10-01-2009 and 10-31-2009 is $0.00.
The average daily balance during this period was 5.00.
The minimum balance during this period was 5.00.
The Annual Percentage Yield Earned for this account is 0.00%.
-
Date
10-01
10-01
10-01
10-02
10-03
Account Summary for Net Checking - -,
Starting Dividend
Balance + Deposits + Paid Withdrawals
4.72 1,117.00 0.00 1,118.41
Transactions for Net Checking - - .~-
Service
Charges
0.00
=
Description
Starting Balance
External Deposit us TREASURY
310 - SUPP SEC Nl*GD*ROBERT W
CROWSON \N1*BE*THELMA R
CROWSON * 3 4 \
Withdrawal
External Deposit US TREASURY
303 - SOC SEC Nl*GD*ROBERT
CROWSON FOR \Nl*BE*THELMA
CROWSON *34* '
ATM Withdrawal 1ST TECH CU 1810
PIONEER PKWY W SPRINGFIELD
ORUS
Drafts/
Debits
Deposits/
Credits
423.00
-423.00
271.00
-270.00
Date Received:
NOV 1 7 2009
Original Submittal
Ending
Balance
3.31
Balance
4.72
427.72
4.72
275.72
5.72
'.
.
.
ROBERT W CROWSON
1434 D ST
SPRINGFIELD OR 97477
Net Checking - ~ONTINUED
Date Description-
10-06 Point,Of Sale withdrawal
AGEINVS 866-686-6429-V
866-6866429 PAUS
10-30 External Deposit US TREASURY
310 - SUPP SEC N1*GD*ROBERT W
CROWSON \N1*BE*THELMA R
CROWSON *34* \
10-30 Withdrawal
,,"; .
~:.- ~..., .... .~.
Drafts/
Debits
-2.41
-423.00
.
Page,
Account Number:
Statement Date:
Deposits/
Credits
423.00
2 of 2
-. ~^ .
10-31-2009
Balance
3.31
426.31
3.31
Date Received:
NOV 1 7 2009
Original Submittal
.
.
Page:
Account Number:
Statement Date:
1 of 1
# ~
08-31-2009
ROBERT W CROWSON
1434 D ST
SPRINGFIELD OR 97477
Statement Summary
Account Number Type
Regular Share Account
Net Checking
Balance
5.00
0.92
Account Summary for Regular Share Account - 31790600
Starting Dividend
Balance + Deposits + Paid Withdrawals
5.00 0.00 0.00 0.00
Service
Charges
0.00
Ending
Balance
5.00
There is no activity for this account.
The amount of Dividend earned between 08-01-2009 and 08-31-2009 is $0.00.
The average daily balance during this period was 5.00.
The minimum balance during this period was 5.00.
The Annual Percentage Yield Earned for this account is 0.00%.
Account Summary for Net Checking - 74035577
Starting Dividend
Balance + Deposits + Paid Withdrawals
0.92 271.00 0.00 271.00
service
Charges
0.00
=
Ending
Balance
0.92
Date
08-01
08-03
08-03
Transactions for Net Checking - 74035577
Drafts/
Debits
Deposits/
Credits
Description
Starting Balance
External Deposit us TREASURY
303 - SOC SEC N1*GD*ROBERT
CROWSON FOR \N1*BE*THELMA
CROWSON *34 "
Withdrawal
271.00
-271.00
Date Received:
NOV I 7 2009
Original SUbmittal
Balance
0.92
271. 92
0.92
'y
.
.
Page:
Account Number:
Statement Date:
1 of 2
-
09-30-2009
ROBERT W CROWSON
1434 D ST
SPRINGFIELD OR 97477
Type
Regular Share Accoun~
Net Checking
Balance
5.00
4.72
.
Account Summary for Regular Share Account -
Starting Dividend
Balance + Deposits + Paid Withdrawals
5.00 0.00 0.00 0.00
Service
Charges
0.00
=
Ending
Balance
5.00
There is no activity for this account.
The amount of Dividend earned between 09-01-2009 and 09-30-2009 is $0.00.
The average daily balance duririg this period was 5.00.
The minimum balance during this period was 5.00.
The Annual Percentage Yield Earned for this account is 0.00%.
Account Summary for Net Checking - .
Starting Dividend
Balance + Deposits + Paid
0.92 714.00 0.00
Transactions for Net Checking -~vJJJl J
Drafts!
Debits
, ,
Withdrawals
710.20
Service
Charges
0.00
=
Ending
Balance
4.72
09-01
09-01
09-03
Description
Starting Balance
External Deposit US TREASURY
310 - SUPP SEC N1*GD*ROBERT W
CROWSON \N1*BE*THELMA R
CROWSON *34" \
Withdrawal
Deposit
External Deposit US TREASURY
303 - SOC SEC N1*GD*ROBERT
CROWSON FOR \N1*BE*THELMA
CROWSON * 3 4 '
Withdrawal
Deposits/
Credits
Date
09-01
09-01
423.00
Balance
0.92
423.92
-400.00
20.00
271.00
23.92
43.92
314.92
09-03
-270.00
44.92
Date Received:
NOV 1 1 2009
Original Submittal
-"~
r"
.
ROBERT W CROWSON
1434 D ST
SPRINGFIELD OR 97477
Net Checking - T II 7 CONTINUED
Date Description
09-04 Point,Of Sa~e Withdrawal JVC
SERVICE +ENGINEERI 800-2525722
NJUS
.. .
Drafts/
Debits
-40.20
.'.
.
Page, 2 of 2
Account Number:
Statement Date: 09~30-2009
Deposits/
Credits
Balance
4.72
Date Received:
NOV 1 7 2009
Original Submittal
Description
CTY TU - Emerg Med Hardship
Postage Fee Type \I - $160
+ 5% Technology Fee
s:\Tidemark\forms\casefees I.rpt
.
Trans
Code
1230
1299
2299
I
Fees Associated8'ith
Case #: DRC2009~044
1434 D ST
STEVEN DALE HARTSOCK
REVOCABLE TRUS
Revenue Date Calculated Original
Account Number Calculated By Amount
100-00000-425002 11/17/2009 EM 0.00
100-00000-425505 11/17/2009 EM 0.00
100-00000-425605 11/17/2009 EM 0.00
Total Due:
Page I of 1
Date Received:
NOV , 7 2009
Original Submittal
11/17/2009
10:54:52AM
Amount
Du.
0.00
0.00
0.00
$0.00
.
.
City of Springfield
Development Services Department
225 Fifth Street
Springfield, OR 97477
A licant Name:
Phone:
Com an :
Fax:
Address:
Owner:
k
Phone:
Com an
Address:
Fax:
.s/. ~
ASSESSOR'S MAP NO:
Address: /
~()
7</77
.~.
Annual Household Income of Pro e
Owner:
Annual Household Income Cannot Exceed:
~on House~old $32.050........
erson House old !t3_6,6QO../
3 Person Household $41,200
4 Person Household $45,750
5 Person Household $49,400
6 Person Household $53,050
The amounts shown are based on HUD income limits and are current as of March 19, 2009. These income limits are subject to change.
Please rovide current a stub or recent income tax return for verification of income.
.","j~,~~;
/
The undersigned acknowled
Applicant Signature:
ation in this application is correct and accurate.
Date:
- /3-09
If the applicant is other than the owner, the owner hereby grants permission for the applicant to act in
his/her behalf.
Emergency Medical
Hardshi Case No.:
~oooLf~
Date:
Date: / /
. -.
-. . . ~
, , ~ -
Owner Signature:
\Th5;::&!i0ii&!L~i1+'N,1i;sii~J:~"0i
.'i4b,kfWti:!",,'r~iky .
NOV 1 7 2009
Revised 5/17/09 ddk
1 of 1
Original SubmittaL