The URL can be used to link to this page

Home My WebLink About17-25D ShufordCoastal Management ENVIRONMENTAL QUALITY November 9, 2017 Mr. Jim Shuford 3700 Pelham Lane Charlotte, NC 28211 ROY COOPER Govemor MICHAEL S. REGAN Secretary BRAXTON DAVIS Director RE: Closure Letter Payment of Proposed Penalty for Violations of the Coastal Area Management Act, Committed in New Hanover County CAMA Violation #17-25D Dear Mr. Shuford: This letter will acknowledge receipt of your check # 0919009908, in the amount of $432.00 for the Notice of Violation dated September 25, 2017 issued by Courtney Spears, representative for the Division of Coastal Management, for the unauthorized construction of a pier and platform adjacent to Banks Channel, on Figure 8 Island, New Hanover County, North Carolina. Once the amount is credited to the account of the Department of Environmental Quality, this matter will be fully and completely closed. Thank you for your cooperation in resolving this violation. If you have any further questions concerning this matter, please contact me at the Wilmington Regional Office, (910) 796-7215. Sincerely, Debra D. Wilson District Manager sks/dw cc: Roy Brownlow, Compliance Coordinator Courtney Spears, Coastal Management Representative, DCM David Kellum, Administrator, Figure 8 Island HOA F111- RSCpp NOV 21'�017 OC"' PAHD Slate of North Carolina I Environmental Quality I Coastal Management 127 Cardinal Drive Ext., Wilmington, NC 28405 910-796-7215 CAMA VIOLATION #17.25D Jim Shuford Property AGREEMENT TO PAY PROPOSED CIVIL ASSESSMENT I understand that the staff of the Department of Environmental Quality will propose the assessment of a civil penalty in the amount of $432 against me for violation of the Coastal Area Management Act, NCGS 113A- 100 et sea, committed on or near property located at 173/175 Beach Road South in New Hanover County, North Carolina. In order to resolve this matter with no further action or expense on my part, I accept responsibility for the violation as described in the Notice of Violation letter dated September 25, 2017, and agree to pay the proposed civil assessment of $432. Al �� Zol '� sc R..13r�� —� DATE SIGNA URE Vc 3-7 o,D ADDRESS 6A440CY-ret NC- 2 gzi/ x -7DY- 607 - W 8 TELEPHONE NUMBER NOV 21 2017 DCM- MHD CITY RECEIVED State of North Carolina l Environmental Quality l Coastal Management t}f'^vI VJII.MiNGTON, NC Wilmington Office 1 127 Cardinal Drive Extension I Wilmington. North Carolina 28405 Q 910 796 7215 1�0 M ENFORCEMENT TRACKING REPORT W f 'Sptl r Violation Case W. (7-7 Rep. �J I ¢ ilia oe Rep. TAM 0 NI/ t Permit No. Violation Description was zptivity permittable?�/ No Initial Discovery Date IV ?hq-- Discovery Method �1 �D In) �� 7 r C2 to Violation Description n—o71 ��(f 14n-12rd r-,f- f oo—yz r ✓�t1Lt/ (�e� (/ Fly t�ed r�1cl�Ti,-Y-Vyk y) Respondent matlon Prior CAMA or DIF Violations: Yes / Prior Case No: RespondentNarre(s) \1tr✓.t,�,,'&JA'� d nrU (Landow nedAgent/Contrador) Address �- 0 IMht LYt City LklaState_�Zp 202J Phone # �� - � 09 Ow7 � Fax #/Email 'i 60711k Corporate Name & Registered agent u<r fT Violation Type: Project Type: Authorizations Required: Site Visits Respondent Site Visits Respondent Resent Resent No Permit 9Private/Conmunity 0 Major CA MA Permit Condition Govt/Public Minor D&F (— - U Expired Permit Q; Comercial General m Q Inconsistentw/Rules Tier Level: I II III Violation Location and Site 'wo ggg/d irits'� 11 Nw Lat/Long lw-o tDescfriiptiionn�� / Project Location: County Nay f"'Itny �VCr ShoielineLength-144- Street Address/ State Road/ Lot #(a) SAV: Not Sure Yes Sandbags Not Sure Yes - _1 PNA: Yes51 o Adjacent Subdivision (Mil Ul ORW.. o Adjacent pyre City twvVI ZIP �iT/-I ( Crit. Help. Yes No Phone # ( ).. Del O"Wer Basin �p,f� CeAr Photos 6) No Adj.V& Body &w V NA— a //man/unlot) WaivarRequired Yes VAr. C In DWQ BufferArea Yes N GosestMaj. Body vVW Specify DMBufferifapplicable� Restoration Extension Granted Yes No NOV Date Q /Z i i- Initial Req. Cone. Date CNOV Date Date Comp. Observed Penalty Assessment Sent to Respondent Date J_t!.l1V.I I I App./FermitFee Rcvd. by Dist. Mgr. Date Assessment Extended Yes No RECE! V Nine 9� 1 20 Restoration Letter Acceptance Date 7J.0409 Ref. Reconlm. Assess. DCM Assess. $ ('� $ $ p $ $ �,Z is Total 3� Formal Assessments, Appeals and Reductions Date Long Form Submitted AssessmentAppealed: Yes No Date Formal CPA Submitted Finally modified Final Assessment$ Date Attorney General's Office for Injunction or Formal Collection Date sentto AG Respondent not responsive to penalty/NOV Injunction to complete restoration Date Collection Letter Sent Date Demand Letter Sent Violation Activities and Impacts AECs Affected: Cw ® PT ES PTS OEA HHF I UBA WA PM: FC: Other: Restoration Rsquired by the Respondent Yes No Wetlands Imoacted? Yes Ifyes,whichtypes: SA DS CJ SY JR LS TY SS SC SP IF BF 404 Me ik 0,11- IM/UilT�ULNifPll�iF rII rL1L%L!/.� N9V � ] 2017 Closing 4 Payment Received $ , 0 v Date // _ / Date Case Gosed 11 — / —14 Coastal Management ENVIRONMENTAL QUALITY October 26, 2017 CERTIFIED MAIL 7016 0910 0000 61714906 RETURN RECEIPT REQUESTED Mr. Jim Shuford 3700 Pelham Lane Charlotte, NC 28211 RE: CAMA VIOLATION #17-25D Dear Mr. Shuford: ROY COOPER Governor MICHAEL S. REGAN Secretary BRAXTON C. DAVIS Director This letter is in reference to the Notice of Violation dated September 25, 2017 that Courtney Spears, representative for the Division of Coastal Management, issued to you for you for enlargement of your fixed pier at 173/175 Beach Road South on Figure 8 Island, New Hanover County. The violation involved Estuarine Waters and Public Trust Areas, which are Areas of Environmental Concern designated by the Coastal Resources Commission. Based upon the adjacent riparian property owner notifications, received on October 24, 2017 by this office, the restoration requested appears to be complete to the satisfaction of the Division of Coastal Management. The Coastal Area Management Act provides that a civil assessment of up to $10,000 plus investigative costs may be assessed for any violation. It is the policy of the Coastal Resources Commission to assess a civil penalty for all violations in order to recover some of the costs of investigating violations and/or to compensate the public for any damage to its natural resources. Under the rules of the Coastal Resources Commission, a proposed civil penalty in the amount of $432 is appropriate for this violation. You may expeditiously resolve this matter prior to the assessment of a formal civil penalty by accepting responsibility for the violation and paying the amount proposed above. In order to do this, you must: (1) sign one of the attached copies of an "Agreement to Pay Civil Assessment;" (2) attach a check or money order for $432 made payable to the North Carolina Department of Environmental Quality (NCDEQ); and, (3) return the signed agreement and payment to this office in the enclosed, self-addressed envelope within ten (10) days of your receipt of this letter. Upon deposit of your check in the Department's account, you will receive a Notice of Compliance officially closing this enforcement action. If you do not send a signed agreement and payment to this office within ten (10) days, the Director of the Division of Coastal Management will formally assess a civil penalty against you. You will then have the opportunity to request a hearing on the penalty or request settlement of the penalty. RECEIVED OCT 3 0 2017 State of North Carolina 1 Environmental Quality I Coastal Management Wilmington Office 1 127 Cardinal Drive Extension I Wilmington. North Carolina 2840��e a ® CITY �` Q 9107967215 M C g Jim Shuford Property October 26, 2017 Page Two Thank you for your time and cooperation in resolving this important matter. If you have any questions, please do not hesitate to contact me at (910) 796-7215. Sincerely, Debra Wilson District Manager Tm/Dw Enclosures cc: Roy Brownlow, Compliance Coordinator, DCM Courtney Spears, Coastal Management Representative, DCM Liz Hair, USACE Chad Coburn, DWR Christine Bouffard, LPO RECEIVED 3 0 2917 O�::�J �,aIHD CITY State of North Carolina I Environmental Quality I Coastal Management Wilmington Office 1 127 Cardinal Drive Extension I Wilmington, North Carolina 2a405 910 796 7215 CAMA VIOLATION #17.25D Jim Shuford Property AGREEMENT TO PAY PROPOSED CIVIL ASSESSMENT I understand that the staff of the Department of Environmental Quality will propose the assessment of a civil penalty in the amount of $432 against me for violation of the Coastal Area Management Act, NCGS 113A- 100 et sec, committed on or near property located at 173/175 Beach Road South in New Hanover County, North Carolina. In order to resolve this matter with no further action or expense on my part, I accept responsibility for the violation as described in the Notice of Violation letter dated September 25, 2017, and agree to pay the proposed civil assessment of $432. DATE SIGNATURE ADDRESS TELEPHONE NUMBER RECEIVED OCT 3 0 2017 DCM- MHD CITY State of North Carolina I Environmental Quality I Coastal Management Wilmington Office 1 127 Cardinal Drive Extension I Wilmington, North Carolina 28405 910 796 7215 Coastal Management ENVIRONMENTAL QUALITY SENT VIA EMAIL Jim Shuford 3700 Pelham Lane Charlotte, NC 28211 jshuford@shurtape.com NOTICE OF VIOLATION September 25, 2017 � T- ROY COOPER Governor MICHAEL S. RECAN Secretary BRAXTON C. DAVIS Director RE: NOTICE OF VIOLATION AND REQUEST TO CEASE UNAUTHORIZED DEVELOPMENT CAMA VIOLATION #17.25D Dear Mr. Shuford: This letter confirms that on September 22, 2017, 1 was onsite at your property located at 173/175 Beach Road South adjacent to Banks Channel located on Figure 8 Island, New Hanover County, North Carolina. The purpose of the visit was to conduct a site visit for a dredge permit application. During the visit, I discovered unauthorized development including replacement of a 100' by 6' fixed pier with a 120 ft2 platform adjacent to Banks Channel. This letter also confirms our September 25th phone call regarding this matter. Information gathered by me for the Division of Coastal Management indicates that you have undertaken major development in violation of the Coastal Area Management Act (CAMA). No person may undertake major development in a designated Area of Environmental Concern (AEC) without first obtaining a permit from the North Carolina Department of Environmental Quality. This requirement is imposed by North Carolina General Statute (N.C.G.S.) 11 3A-1 18. I have information that indicates you have undertaken or are legally responsible for replacement of a 100' by 6' fixed pier with a 120 ft2 platform (720 ft.2) on the aforementioned property. This activity took place in Estuarine Water and Public Trust Areas that are contiguous with Banks Channel. This area of Banks Channel is also classified as Outstanding Resource Water (ORW) by the Environmental Management Commission (EMC). Estuarine Water and Public Trust areas are designated as Areas of Environmental Concern (AEC). No CAMA permit was issued to you for work in these areas. Based on these findings, I am initiating an enforcement action by issuing this Notice of Violation for violation of the Coastal Area Management Act. I request that you immediately CEASE AND DESIST any further development and contact me about this matter. A civil assessment of up to $10,000 plus investigative costs may be assessed against any violator. Each day that the development described in this Notice is continued or repeated may constitute a separate RECEIVED SEP 2 S 2017 DCM- MHD CITY State of North Carolina Environmental Quality I Coastal Management Wilmington Office 1127 Cardinal Drive Extension I Wilmington, North Carolina 28405 910 796 7215 Jim Shuford September 25th, 2017 Page Two violation that is subject to an additional assessment of $10,000. An injunction or criminal penalty may also be sought to enforce any violation in accordance with N.C.G.S.113A-126. It is the policy of the Coastal Resources Commission to assess a civil penalty plus investigative costs against all violations. This is done to recoup some of the costs of investigating the violation and/or to compensate the public for any damage to its natural resources. The amount assessed will depend upon several factors, including the nature and area of the resources that were affected and the extent of the damage to them. Based upon review of the Coastal Area Management Act, Coastal Resource Commission's rules, and the local jurisdiction's Land Use Plan, the activity you have undertaken appears consistent with the guidelines for Areas of Environmental Concern. Therefore, restoration of the impacted area will include notification of the adjacent riparian property owner's via certified mail return receipt requested. Thank you for your time and cooperation in resolving this important matter. The relevant statutes and regulations are available from this office, and I am willing to assist you in complying with the requirements of these laws. If you have any questions about this or related matters, please call me at (910) 796-7423. Upon my submission of an enforcement report to the District Manager, you will be notified as to the amount of a civil assessment for undertaking development without first obtaining the proper permit(s). Please sign and return the attached restoration agreement. Sin rr> ly, Courtney S rs Coastal Management Cc: Debra Wilson, District Manager, DCM Roy Brownlow, Compliance Coordinator, DCM David Kellem, Figure 8 Island HOA Christine Bouffard, LPO Chad Coburn, DWR Tyler Crumbley, USACE �® 901 State of North Carolina I Environmental Quality I Coastal Management Wilmington Office 1 127 Cardinal Drive Extension I Wilmington, North Carolina 28405 9107967215 .1 RESTORATION PLAN For Jim Shuford CAMA Violation No. 17-25D Property located at 173/175 Beach Road South, Wilmington, New Hanover County 1. Notify the adjacent riparian property owners of the development of a 100' by 6' fixed pier with a 120ft2 platform via certified mail return receipt requested, or obtain signatures of no objection via hand -delivery (forms included). Return certified mail return receipts (green cards) or signed notification forms with no objections to the Division of Coastal Management. I, Jim Shuford, agree to complete this restoration to the satisfaction of the Division of Coastal Management (DCM) by October 25th, 2017, or provide an explanation for non-compliance and a reasonable request for time extension. When corrective actions are complete, I will notify the DCM and provide copies of the signed return receipts or signatures of no objection. SIGNATURE: DATE: It is the policy of the Coastal Resources Commission to assess a civil penalty plus investigative costs against all violations. The amount assessed will depend upon several factors, including the nature and area of the resources that were affected and the extent of the damage to them. If restoration is not undertaken or satisfactorily completed, a substantially higher civil assessment will be levied and an injunction sought to require restoration. RECEIVED SEP 2 8 2017 DCM- MHD CITY State of North Carolina I Environmental Quality I Coastal Management Wilmington Office 1127 Cardinal Drive Extension I Wilmington, North Carolina 28405 9107%7215 M ENFORCEMENT n .� O��t 's/TRACKING REPORT Rep. �luer Violgon Case W. 'sly )lia a Rep. �•4 � ❑ Permit No. NI/¢ I cln,l() S -w 7YU iA ❑ (if applicable) Initial Discovery Date DiscoveryMethod Respondent Names) Address M 17( Phone# TIW — Violation Type: No Permit Permit Condition Q Expired Permit Inconsistentw/Rules r. or i.n l ty L�/ f ^ State__ ZL �L9Z( i Fax #/Email�S d Project Type: 9Private/Community Govt./Public Commercial Tier Level: I (I Authorizations Required: Major] CAMA Mnor n D&F Ff General Violation Location and Site Description Project Location: County Nt.W StreetAddress/State Road/Lot #(s) Subdivision City W l Site Visits Respondent Site Visits Respondent Present Present Lat/Long Z.c gLr61.qq aN Shoal i ne Length:F � / SAV: Not Sure Yes — Sandbags: Not Sure Yes PNA: Yes o Adjacent ORW.. 5 o Adjacent Crit. Hab. Yes No Phone # (71a%) Wv DLl —ft'�Ver Basin i Photos Now Adj. V*. Body a�Imanlunlo,) WaiverRequired Yes /N0 ��V�!' �WI In DWO BufferAxes Yes N % Closest Maj. Mr. Body C Specify DWQ Buffer if appl icable: Restoration Extension Granted Yes No NOV Date CNOV Date Penalty Assessment Sent to Respondent Date Rcvd. by Dist NIgr. Date Assessment Extended Yes No RECE ZIP Initial Req. Comp. Date I D!?`I'(l "P Date Comp. Observed Restoration Letter Acceptance Date )Cm- MHD CIPZ Formal Assessments, Appeals and Reductions Date Long Form Subr itted AssessmentAppealed: Yes No Date Formal CPA Submitted Q_ Penalty modified Final Assessment$ Date Attorney General's Office for Injunction or Formal Collection Date sent to AG [I Respondent not responsive to penalty/NOV injunction to complete restoration Date Collection Letter Sent Date Demand Letter Sent Violation ActiHties and Impacts AECs Affected- Wetlands Irpacted?Yes IF yes, whichtypes: Cw ® PT ES PTS OEA HHF I UBA WA SA DS CJ SY JR LS TY PWS: FC: SS Sc SP IF BF 404 Other. �� Restoration Required by the Respondent / res f No Closing Payment Received $ Date Date Case Closed Coastal Management ENVIRONMENTAL QUALITY SENT VIA EMAIL Jim Shuford 3700 Pelham Lane Charlotte, NC 28211 jshuford@shurtape.com NOTICE OF VIOLATION September 25, 2017 ROY COOPER Governor MICHAEL S. REGAN Secretary BRAXTON C. DAVIS Director RE: NOTICE OF VIOLATION AND REQUEST TO CEASE UNAUTHORIZED DEVELOPMENT CAMA VIOLATION #17-25D Dear Mr. Shuford: This letter confirms that on September 22, 2017, 1 was onsite at your property located at 173/175 Beach Road South adjacent to Banks Channel located on Figure 8 Island, New Hanover County, North Carolina. The purpose of the visit was to conduct a site visit for a dredge permit application. During the visit, I discovered unauthorized development including replacement of a 100' by 6' fixed pier with a 120 ft2 platform adjacent to Banks Channel. This letter also confirms our September 25th phone call regarding this matter. Information gathered by me for the Division of Coastal Management indicates that you have undertaken major development in violation of the Coastal Area Management Act (CAMA). No person may undertake major development in a designated Area of Environmental Concern (AEC) without first obtaining a permit from the North Carolina Department of Environmental Quality. This requirement is imposed by North Carolina General Statute (N.C.G.S.) 113A-118. I have information that indicates you have undertaken or are legally responsible for replacement of a 100' by 6' fixed pier with a 120 ft2 platform (720 ft2) on the aforementioned property. This activity took place in Estuarine Water and Public Trust Areas that are contiguous with Banks Channel. This area of Banks Channel is also classified as Outstanding Resource Water (ORW) by the Environmental Management Commission (EMC). Estuarine Water and Public Trust areas are designated as Areas of Environmental Concern (AEC). No CAMA permit was issued to you for work in these areas. Based on these findings, I am initiating an enforcement action by issuing this Notice of Violation for violation of the Coastal Area Management Act. I request that you immediately CEASE AND DESIST any further development and contact me about this matter. A civil assessment of up to $10,000 plus investigative costs may be assessed against any violator. Each day that the development described in this Notice is continued or repeated may constitute a separate State of North Carolina ! Environmental Quality I Coastal Management Wilmington Office 1127 Cardinal Drive Extension I Wilmington. North Cai olma 28405 910 796 7215 Jim Shuford September 25th, 2017 Page Two violation that is subject to an additional assessment of $10,000. An injunction or criminal penalty may also be sought to enforce any violation in accordance with N.C.G.S. 113A-126. It is the policy of the Coastal Resources Commission to assess a civil penalty plus investigative costs against all violations. This is done to recoup some of the costs of investigating the violation and/or to compensate the public for any damage to its natural resources. The amount assessed will depend upon several factors, including the nature and area of the resources that were affected and the extent of the damage to them. Based upon review of the Coastal Area Management Act, Coastal Resource Commission's rules, and the local jurisdiction's Land Use Plan, the activity you have undertaken appears consistent with the guidelines for Areas of Environmental Concern. Therefore, restoration of the impacted area will include notification of the adjacent riparian property owner's via certified mail return receipt requested. Thank you for your time and cooperation in resolving this important matter. The relevant statutes and regulations are available from this office, and I am willing to assist you in complying with the requirements of these laws. If you have any questions about this or related matters, please call me at (910) 796-7423. Upon my submission of an enforcement report to the District Manager, you will be notified as to the amount of a civil assessment for undertaking development without first obtaining the proper permit(s). Please sign and return the attached restoration agreement. Sin ly, Courtney S rs� Coastal Management Cc: Debra Wilson, District Manager, DCM Roy Brownlow, Compliance Coordinator, DCM David Kellem, Figure 8 Island HOA Christine Bouffard, LPO Chad Coburn, DWR Tyler Crumbley, USACE State of North Carolina I Environmental Quality I Coastal Management Wilmington Office 1 127 Cardinal Drive Extension I Wilmington. North Carolina 28405 9107%7215 RESTORATION PLAN For Jim Shuford CAMA Violation No.17-25D Property located at 173/175 Beach Road South, Wilmington, New Hanover County 1. Notify the adjacent riparian property owners of the development of a 100' by 6' fixed pier with a 120ft2 platform via certified mail return receipt requested, or obtain signatures of no objection via hand -delivery (fors included). Return certified mail return receipts (green cards) or signed notification fors with no objections to the Division of Coastal Management. I, Jim Shuford; agree to complete this restoration to the satisfaction of the Division of Coastal Management (DCM) by October 25m, 2017, or provide an explanation for non-compliance and a reasonable request for time extension. When corrective actions are complete, I will notify the DCM and provide copies of the signed return receipts or signatures of no objection. SIGNATURE: DATE: It is the policy of the Coastal Resources Commission to assess a civil penally plus investigative costs against all violations. The amount assessed will depend upon several factors, including the nature and area of the resources that were affected and the extent of the damage to them. If restoration is not undertaken or satisfactorily completed, a substantially higher civil assessment will be levied and an injunction sought to require restoration. State of North Carolhm I Erwi munemal CiWity l Coastal Management, Wilmington Office 1127 CmdMal Drive Extension I Wilmington, North Carotlna 28405. 9107967215 CERTIFIED MAIL • RETURN RECEIPT REQUESTED DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM Name of Property Owner. Address of Property: Agent's Name #: Agent's phone #: (Lot or Street #, Street or Road, City & County) Mailing Address: I hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit has described to me as shown on the attached drawing the development they are proposing. A description or drawina.'with dimensions, must be Provided with this letter. I have no objections to this proposal.. I have objections to this proposal. ova objections to whatis being proposed, you must noW the Division of Coastal Management (DCM) in within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext, Eton, NC, 284053845. DCM representatives can also be contacted at (910) 798-7215. No response Is gyred the same as no obiecdon If von have been notified by Cerdtied Mail. WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me. (if you wish to waive the setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback requirement. I do not wish to waive the 15' setback requirement. (Property Owner Information) Signature Print or Type Name Mailing Address City/State0p Telephone Number Date (Adjacent Property Owner Information) Signature or Type Name Mailing Address City/Statealp Telephone Number Date Revised 611812012 ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I Hereby, certify that I.own property adjacent to s (Name of.Property Owner) property located at (Address,Lot, Block, Road, etc.) on in N.C. (11Vaterbody) ptynown andlor County) The applicant has described to me, as shown below, the development proposed at the above location. I have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (Individual proposing development must fill in description below or attach a site drawing) WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a minimum distance of 16 from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback requirement. I do not wish to waive the 15' setback requirement. (Property Owner Information) (Adjacent Property Owner Information) Signature Print or Type Name Mailing Address City/State/Zip Telephone Number Date Signature Print or Type Name Mailing Address City/State/Zip Telephone Number (Revised 6/1KO12)