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By signing, the undersigned certifies that he/she has read and understood the submittal requirements outlined, andthathe/she understands that omission of any listed item may cause delay in processing the application. I (We), theundersigned, acknowledge that the information supplied in this application is complete and accurate to the best of <br />my (our) knowledge. <br />PROPERTY OWNER OF TAX LOT: 1401 <br />Name (print): The Estate of Nancy Ann Chase, deceased By: David Hollomon, Executor <br />Address: 826 NE Hidden Valley Drive, Unit 2 Email: davefor.ncestate@yahoo.com <br />City/State/Zip: Bend, Oregon 97701 Phone: q ` Sq1-ja4 <br />Signature: Date: <br />SURVEYOR: <br />Name (print): <br />Company/Organization: <br />Address: <br />City/State/Zip: Phone: <br />E-mail: <br />Signature: Date: <br />REPRESENTATIVE (If different from Surveyor): <br />Name (print): Sean M. Barnes <br />Company/Organization: Eastmark Capital Group LLC <br />Address: 1420 Fifth Avenue, Suite 2600 <br />City/State/Zip: Seattle, WA 98101 Phone: 206.521.0240 Fax: <br />E-mail: sean@eastmarkcapitalgroup.com <br />Signature: Date: <br />Attached additional sheets if necessary. <br />Annexation Application _Prepared: June 4, 2018ChevyChaseLane <br />Eugene, Oregon 97401 Prepared By: Eastmark Capital GroupE <br />Page 5 of 11September 10, 2018, Meeting - Item 2D