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Deed Restriction 2023-0003897RECORDING REQUESTED BY: California Department of Parks and Recreation Office of Grants and Local Services WHEN RECORDED MAIL TO: Office of Grants and Local Services PO Box 942896 Sacramento, CA 94296-0001 Attn: Karen Sims DOC# 2023-0003897 IIIII III I IIIll11111111111111111111111111111111111111111111111111111 Jan 06, 2023 08:53 AM OFFICIAL RECORDS JORDAN Z. MARKS, SAN DIEGO COUNTY RECORDER FEES: $0.00 (SB2 Atkins: $0.00) PAGES: 25 SPACE ABOVE THIS LINE RESERVED FOR RECORDER's USE DEED RESTRICTION I. WHEREAS, City of Poway (hereinafter referred to as "Owner(s)" is/are recorded owner(s) of the real property described in Exhibit A, attached and incorporated herein by reference (hereinafter referred to as the "Property"); and II. WHEREAS, the California Department of Parks and Recreation (hereinafter referred to as "DPW") is a public agency created and existing Linder the authority of section 5001 of the California Public Resources Code (hereinafter referred to as the "PRC"). And III. WHEREAS, Owner(s) (or Grantee) applied to DPR for grant funds available pursuant to the California Drought, Water, Parks, Climate, Coastal Protection, and Outdoor Access for All of 2018 Parks Bond Act, 2018 Parks Bond Act Per Capita Program for Replace playground including adding interactive interpretive elements and shade sails on the Property; and IV. WHEREAS, on July 1, 2020, DPR's Office of Grants and Local Services conditionally approved Grant 18-37-020, (hereinafter referred to as "Grant") for Replace playground including adding interactive interpretive elements and shade sails on the Property, subject to, among other conditions, recordation of this Deed Restriction on the Property; and V. WHEREAS, but for the imposition of the Deed Restriction condition of the Grant, the Grant would not be consistent with the public purposes of the 2018 Parks Bond Act, 2018 Parks Bond 2Z-lll Act Per Capita Program and the funds that are the subject of the Grant could therefore not have been granted; and VL WHEREAS, Owner(s) has/ve elected to comply with the Deed Restriction of the Grant, so as to enable Owner(s), to receive the Grant funds and perform the work described in the Grant; NOW, THEREFORE, in consideration of the issuance of the Grant funds by DPR, the undersigned Owner(s) for himself/herself/themselves and for his/her/their heirs, assigns, and successors - in -interest, hereby irrevocably covenant(s) with DPR that the condition of the grant (set forth at paragraph(s) 1 through 5 and in Exhibit B hereto) shall at all times on and after the date on which this Deed Restriction is recorded constitute for all purposes covenants, conditions and restrictions on the use and enjoyment of the Property that are hereby attached to the deed to the Property as fully effective components thereof. 1. DURATION. (a) This Deed Restriction shall remain in full force and effect and shall bind Owner(s) and all his/her/their assigns or successors -in -interest for the period running from July 1, 2018 through June 30, 2048. 2. TAXES AND ASSESMENTS. It is intended that this Deed Restriction is irrevocable and shall constitute an enforceable restriction within the meaning of a) Article XIII, section 8, of the California Constitution; and b) section 402.1 of the California Revenue and Taxation Code or successor statute. Furthermore, this Deed Restriction shall be deemed to constitute a servitude upon and burden to the Property within the meaning of section 3712(d) of the California Revenue and Taxation Code, or successor statute, which survives a sale of tax -deeded property. 3. RIGHT OF ENTRY. DPR or its agent or employees may enter onto the Property at times reasonably acceptable to Owner(s) to ascertain whether the use restrictions set forth above are being observed. 4. REMEDIES. Any act, conveyance, contract, or authorization by Owner(s) whether written or oral which uses or would cause to be used or would permit use of the Property contrary to the terms of this Deed Restriction will be deemed a violation and a breach hereof. DPR may pursue any and all available legal and/or equitable remedies to enforce the terms and conditions of this Deed Restriction up to and including a lien sale of the property. In the event of a breach, any forbearance on the part of DPR to enforce the terms and provisions hereof shall not be deemed a waiver of enforcement rights regarding any subsequent breach. SEVERABILITY. If any provision of these restrictions is held to be invalid, or for any reason becomes unenforceable, no other provision shall be affected or impaired. Dated:l Vot-mtv `I 2001- Business Name (if property is owned by a business): City of Poway Owner(s) Name(s): City of Poway Signed: Chris Hazeltine, City Manager PRINT/TYPE NAME & TITLE OF ABOVE (GRANTEE'S AUTHORIZED REPRESENTATIVE) Signed: PRINT/TYPE NAME & TITLE OF ABOVE (ADDITIONAL SIGNATURE, AS REQUIRED) **NOTARY ACKNOWLEDGEMENT ON THE NEXT PAGE** CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Diego On November 9, 2022 Date personally appeared before me, Yvonne Mannion, Notary Public Here Insert Name and Title of the Officer Chris Hazeltine Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. *my YVONNEMANNION Notary Public . California San Diego County Commission # 2363699 Comm. Expires Jul 1, 2025 r I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature `� Signature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Deed Restriction Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Number of Pages: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: 02016 National Notary Association • www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 ibit A (Legal Decrj,�;,rt) RRCORDINO RROURRTRD ■Y 1 Glesuy,, Wright, Jacobs 6 Schell FILEIPAG25JA ! N0, �` 5 ... wllu nceAws R.au .. RlCORDED BOORF 7i Dr TITLE INSIJRANC & TRUST CO. (- 1 FES 10 9AAM71 M.e s. Schell OFFICIAL RECORDS SAN DI're COUNTY CALIF, 1434 Fifth Avenue MARLEY F, BLOOM 2an Diego, California 92101 RECORDER '''NO TAX DLTn j .MN r.a R.1.+.MR 10 CC A80YR THIS LINK FOR RRCORDRR'■ USK M.R. rPoway Municipal Water District Documentary Transfer Tax S w 12324 Oak Knoll Road Computed on full value i6po�fy convoyed. or computed on full value less liens and en- cIN a r..N LPoway, California 92064 J n cumbrance re iq t o " n at tirgp of sale., 514naturei f declaraft or agent dete Minn tax Firm No — Grant Deed .......... _........ .............. ......_ THIS PORN IURNIEMR0 by YIYLa INSURANCR AND TRUST COMPANY FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, Probat ODESSA M. STERLING, Conservator of the Estate of Floyd E. Clemens/ 92693 CECIL M. BRUCE, as Distributes under the Will of Robert Frederick Bruce, D FercSTMT11V JOHN B. STERLING and ODESSA M. STERLING, husband and wife POWAY MUNICIPAL WATER DISTRICT, a public corporation, The following described real property in the County of San Diego . State of California: See Exhibit A attached hereto. 4inDeed is made pursuant to Order Authorizing Sale in the Estate of Floyd E. Clemens, Probate No. 92693, a certified copy of which is recorded concurrently herewith. Dated Noveml>er 30 3970 STATE OF CALIFORNIA COUNTY I SAN D. On I 1 mrr.,ppllle under. alµmd 'olary 1'u In nl Inr a I, 9ARjXryi9S?;ptvsrnl O�aesa M..iiasj,inq�jCe _Bruce and Cohn B. Ster]inq a,nd / _OdAMNA M. Sterling, hunhanA And t\ wife., 4m.rn In me I., 1. the perr.n�_wLu.e mmr�0i0auLrTIL.J lu IUe wldh:� Indrumenl and sc1inu Ward Ihst—they '—wed 16 ..me. WITNESS my load snd 0ki.1 11ArMIUM'�C P. CAI 71 i of Odessa M. Sterlin Conserva r -��A_ Clemens Cec�iluce, a M. BrD ,tributes and thy Will oZgohert Freda_ i G eruce, Deceased VOessa M, sterling the Wife of John B. Sterl No. x� •o 177M1 Nam. ITl.w-,rY-:J. ,:`toti mn. ... r.. w.m .+ma ..0 •� Title Order No, tti� y ` Escrow or Loan No MAIL TAX STATEM!NTS AS DIRlCTlD ABOVE ^ Non -Order Search Page 1 of 3 Requested By: kevinfarrell, Printed: 12/2/2021 11:14 AM Doc: SD:1971 00025525 =CRIPTION, EXHIBIT A PARCEL I THAT PORTION OF SECTION 29 AND INCLUDING ANY PORT:ON OF SECTION 32. TOWNSHIP 13 SOUTHP RANGE I W-57. SAN BERNARDINO BASE AND NERIDIANP :N THE COUNTY OF SAN D:EGOP STATE OF CALIFORNIA, ACCORDING TO THE OFFICIAL PLAT THEREOF. LYING 'WITHIN A PARCEL OF LAND DESCRIBED AS FOLLOWSi BEGINNING AT THE NORTHEAST CORNER OF SAID SECTION 291 THENCE ALO;:G THE EAST LINE OF SAID SECTION. SOUTH 1003'36" EAST. 2734.90 FEET TO A 1 2/2 INCH CAPPED PIPE SET FOR THE EAST QUARTER CORNER OF SAID SECTION. AS SHOlw.N ON RECORD OF SURVEY MAP NO. 2658, FILED IN THE OFFICE OF COUNTY RECORDER OF SAN DIEGO COUNTYI THENCE SOUTH 89005101" WEST. 2982.45 FEET TO A SET STONE IN A STONE MOUNO. SHOWN AS FOUND ON SA:D RECORD OF 5URVEY MAP NO. 2658. BEING THE TRUE POINT OF BEGINN:NGI THENCE ALONG THE STRAIGHT LINE CONNECTING SAID SET STONE WITH THE WEST QUARTER CORNER OF SAID SECTION 29r AS SHOWN ON SAID RECORD OF SURVEY YAP NO. 2638. SOUTH 89045111" (JEST 1305.29 FEET TO A 1 1/2 INCH CAPPED PIPE. AS SHOWN ON SAID RECORD OF SURVEY YAP NO. 26581 THENCE SOUTHERLY IN A STRAIGHT LINE APPROXIMATELY 2700 FEET TO A 2 INCH IRON PIPE MARKED R.E. 27181 SHOWN AS FOUND ON RECORD OF SURVEY ,YAP NO. 38981 FILED IN THE OFFICE OF COUNTY RECORDER OF SAN D:EGO COUNTY# AND DESIGNATED THEREON AS "AGREED PROPERTY CORNER BETWEEN O'dNERS"$ THENCE SOUTH 89038' EAST# 1347.36 FEET TO A 1 1/2 INCH PIPE MARKED R.E. 2718. SET FOR THE SOUTH QUARTER CORNER OF SAID SECT:ON 2St AS SHOWN ON SAID RECORD OF SURVEY MAP No. 38981 THENCE NORTHERLY IN A STRA:GHT LINE TO THE TRUE POINT OF BEGINNING. PARCEL 21 THE NORTH HALF OF THE NORTHWEST QUARTER OF SEC71ON 32P TOWNSHIP 13 SOUTH. RANGE I WEST9 SAN BERNARDINO BASE AND MER:D:AN, IN THE COUNTY OF SAS DIEGO. STATE OF CAL:FORN:Ai ACCORDING TO OFFICIAL PLAT THEREOF. EXCEPTING ANY PORTION LYING NORTHERLY OF A LINE DESCRIBED AS FCLLC';.%i BEGINNING AT THE NORTHEAST CORNER OF SAID SECTION 32t AS SHOWN O>: RECORD OF SURVEY NIAP NO. 30981 FILED IN THE OFFICE OF COUNTY RECCRDEEn OF SAP; D:EGC CCUNTYJ THENCE SOUTH 69006'06" WESTP 3212.47 FEET TO A 1 1/2 INCH P:PE" MARRED F.E. 27169 SET FOR THE SOUTH QUARTER CORNER OF SA:D SECT;ON 29r AS SHOWN ON SA:D RECORD CF SURVEY ,MAP NO. 3598P THENCE NORTH 89038' WESTP 1347.36 FEET TO A• 2 INCH P:PE MIARKED R.E. 2718. SHv'n"; AS �OUAD ON RECORD OF SURVEY ,MAP NO. 38961 FILED I1: THE OFFICE OF COUNTY RECORDER OF SAN DIEGO COUNTY AND DESIGNATED THEREON AS "AGR" D PROPERTY CORNER BETWEEN 041NERS"l THEi;CE NORTH 890 38' 4ESTr 7.346.22 FEET TO THE SOUTHWST CORNER OF SAID SECT:ON 299 AS SHO:.a OP; SAID RECORD OF SURVEY %!A? NO. 3898. EXHIBIT A L x -o w3 *mj Non -Order Search Page 2 of 3 Requested By: kevinfarrell, Printed: 12/2/2021 11:14 AM Doc: SD:1971 00025525 CERTIFICATE OF ACCEPTANCE I, JOHN R. SCHELL, as attorney and agent for Poway Municipal Water District, a public corporation, make the following certi- fication on its behalf: This is to certify that the interest in real property conveyed by the deed or grant dated November 30, 1970, from ODESSA M. STERLING, Conservator of the Estate of Floyd E. Clemens, Probate No. 92693, CECIL M. BRUCE, as Distributee under the Will of Robert Frederick Bruce, Deceased, and JOHN B. STERLING and ODESSA M. STERLING, husband and wife, to Poway Municipal Water District, a political corporation and/or governmental agency is hereby accepted by the undersigned agent on behalf of the Board of Directors pursuant to authority conferred by resolution of the Board of Directors adopted on September 10, 1969, and the grantee consents to recordation thereof by its duly authorized agent. Dated: February 5, 1971. L POWAY MUNICIPAL WATER DISTRICT By t John R. c e x .o N CJ� N CJS .J Non -Order Search Doc: SD:1971 00025525 Page 3 of 3 Requested By: kevinfarrell, Printed: 12/2/2021 11:14 AM a RESOLUTION NO. 1276-81 FINAL RESOLUTION OF THE BOARD OF DIRECTORS OF POWAY MUNICIPAL WATER DISTRICT WHEREAS, the citizens of Poway voted to establish the POWAY * MUNICIPAL WATER DISTRICT on February 1, 1954; and WHEREAS, the POWAY pUNICIPAL WATER DISTRICT, its Directors and staff accepted the challenge of the charter to respond to the needs of the = community; and WHEREAS, the POWAY MUNICIPAL WATER DISTRICT has, through its timely response, engendered the abundant goodwill and freely declared a appreciation of the citizens of Poway; and WHEREAS, the citizens of Poway have determined that the work of the POWAY MUNICIPAL WATER DISTRICT is now complete, BE IT THEREFORE RESOLVED that this Board of Directors, speaking on behalf of every individual who has ever been priviledged to be•a member of v this body, does hereby declare our deep gratitude to the citizens of Poway, for the honor bestowed on us and for the gracious cooperation and outstanding support of the people of Poway. BE IT FURTHER RESOLVED that, with the passing of its rights, duties, obligations and assets to the City of Poway, successor to the POWAY MUNICIPAL WATER DISTRICT, this Board of Directors of the POWAY MUNICIPAL WATER DISTRICT does also pass on the "Spirit of Service and Sensitivity to Public Need- which has characterized the history of local government in this community. V FINALLY, BE IT RESOLVED that our prayers and best wishes be forever extended to the entire community of Poway. PASSED and ADOPTED this 31st day of January, 1981 4 mes. C. StanCa , res ent -William A. Cole, Vice Preside Sanford B. Hunt, Secretary d/ tin - & +� Carl M. Edmonds, Treasurer DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A Exhibit B (Grant CONTRACT) State of California - Natural Resources Agency DEPARTMENT OF PARKS AND RECREATION GRANT CONTRACT 2018 Parks Bond Act Per Capita Grant Program GRANTEE City of Poway THE PROJECT PERFORMANCE PERIOD is from July 01, 2018 through June 30, 2024 CONTRACT PERFORMANCE PERIOD is from July 01, 2018 through June 30, 2038 The GRANTEE agrees to the terms and conditions of this Contract, and the State of California, acting through its Director of the Department of Parks and Recreation, pursuant to the State of California, agrees to fund the total State grant amount indicated below. The GRANTEE agrees to complete the GRANT SCOPE(s) as defined in the GRANT SCOPE/Cost Estimate Form or acquisition documentation for the application(s) filed with the State of California. The General and Special Provisions attached are made a part of and incorporated into the Contract. City of Poway tee By STATE OF CALIFORNIA DEPARTMENT OF PARKS AND RECREATION nature of Authorized Representative) Title City Manager Date 1Z 1-Zo (� a t DocuSigned by: By Date /187/L E41C... CERTIFICATION OF FUNDING For State Use Only) _ CONTRACT NO AMENDMENT NO FISCAL SUPPLIER I.D. PROJECT NO. C9802285 0000039962 18-37-021 AMOUNT ENCUMBERED BY THIS DOCUMENT FUND. $30,755.00 Drought, Water, CIn Air, Cstl Protc, Outdoor Fund PRIOR AMOUNT ENCUMBERED FOR THIS ITEM CHAPTER STATUTE FISCAL YEAR CONTRACT 3790-101-6088 23 19 2021/22 TOTAL AMOUNT ENCUMBERED TO DATE Reporting Structured, Account/AltAccount. ACTIVITY CODE PROJECT / WORK PHASE S $30,755.00 37900091 5432000-5432000000 69803 379000001837021 DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A I. RECITALS This CONTRACT is entered into between the California Department of Parks and Recreation (hereinafter referred to as "GRANTOR," "DEPARTMENT" or "STATE") and City of Poway (hereinafter referred to as "GRANTEE"). The DEPARTMENT hereby grants to GRANTEE a sum (also referred to as "GRANT MONIES") not to exceed $30,755 , subject to the terms and conditions of this AGREEMENT and the 2019/20 California State Budget, Chapter 23, statutes of 2019, Item number — 3790-101-6088 (appropriation chapter and budget item number hereinafter referred to as "PER CAPITA GRANT"). These funds shall be used for completion of the GRANT SCOPE(S). The Grant Performance Period is from July 01. 2018 to June 30. 2024 il. GENERAL PROVISIONS A. Definitions As used in this CONTRACT, the following words shall have the following meanings: 1. The term "ACT' means the California Drought, Water, Parks Climate, Coastal Protection, and Outdoor Access for All Act of 2018, as referred to in section I of this CONTRACT. 2. The term "APPLICATION" means the individual project APPLICATION packet for a project pursuant to the enabling legislation and/or grant program process guide requirements. 3. The term "DEPARTMENT' or "STATE" means the California Department of Parks and Recreation. 4. The term "DEVELOPMENT' means capital improvements to real property by means of, but not limited to, construction, expansion, and/or renovation, of permanent or fixed features of the property. 5. The term "GRANTEE" means the party described as the GRANTEE in Section I of this CONTRACT. 6. The term "GRANT SCOPE" means the items listed in the GRANT SCOPE/Cost Estimate Form or acquisition documentation found in each of the APPLICATIONS submitted pursuant to this grant. 7. The term "PROCEDURAL GUIDE" means the document identified as the "Procedural Guide for California Drought, Water, Parks, Climate, Coastal Protection, and Outdoor Access For All Act of 2018 Per Capita Program." The DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A PROCEDURAL GUIDE provides the procedures and policies controlling the administration of the grant. B. Project Execution Subject to the availability of GRANT MONIES, the STATE hereby grants to the GRANTEE a sum of money not to exceed the amount stated in Section I of this CONTRACT, in consideration of, and on condition that, the sum be expended in carrying out the purposes as set forth in the scope described in the enabling legislation and referenced in the APPLICATION, Section I of this CONTRACT, and under the terms and conditions set forth in this CONTRACT. The GRANTEE shall assume any obligation to furnish any additional funds that may be necessary to complete the GRANT SCOPE(S). The GRANTEE agrees to submit any change or alteration from the original GRANT SCOPE(S) in writing to the STATE for prior approval. This applies to any and all changes that occur after STATE has approved the APPLICATION. Changes in the GRANT SCOPE(S) must be approved in writing by the STATE. 2. The GRANTEE shall complete the GRANT SCOPE(S) in accordance with the time of the Performance Period set forth in Section I of this CONTRACT, and under the terms and conditions of this CONTRACT. 3. The GRANTEE shall comply with the California Environmental Quality Act (Public Resources Code, Section 21000, et seq., Title 14, California Code of Requlations, Section 15000 et seq.). 4. The GRANTEE shall comply with all applicable current laws and regulations affecting DEVELOPMENT projects, including, but not limited to, legal requirements for construction contracts, building codes, health and safety codes, and laws and codes pertaining to individuals with disabilities, including but not limited to the Americans With Disabilities Act of 1990 (42 U.S.C. §12101 et seq.) and the California Unruh Act (California Civil Code §51 et seq.). C. Project Costs 1. GRANTEE agrees to abide by the PROCEDURAL GUIDE. 2. GRANTEE acknowledges that STATE may make reasonable changes to its procedures as set forth in the PROCEDURAL GUIDE. If STATE makes any changes to its procedures and guidelines, STATE agrees to notify GRANTEE within a reasonable time. D. Project Administration 1. If GRANT MONIES are advanced for DEVELOPMENT projects, the advanced funds shall be placed in an interest bearing account until expended. Interest earned on the advanced funds shall be used on the project as approved by the STATE. If grant monies are advanced and not expended, the unused portion of the 2 DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A grant and any interest earned shall be returned to the STATE within 60 days after project completion or end of the Grant Performance Period, whichever is earlier. 2. The GRANTEE shall submit written project status reports within 30 calendar days after the STATE has made such a request. In any event, the GRANTEE shall provide the STATE a report showing total final project expenditures within 60 days of project completion or the end of the grant performance period, whichever is earlier. The Grant Performance Period is identified in Section I of this CONTRACT. 3. The GRANTEE shall make property or facilities acquired and/or developed pursuant to this contract available for inspection upon request by the STATE. E. Project Termination 1. Project Termination refers to the non -completion of a GRANT SCOPE. Any grant funds that have not been expended by the GRANTEE shall revert to the STATE. 2. The GRANTEE may unilaterally rescind this CONTRACT at any time prior to the commencement of the project. The commencement of the project means the date of the letter notifying GRANTEE of the award or when the funds are appropriated, whichever is later. After project commencement, this CONTRACT may be rescinded, modified or amended only by mutual agreement in writing between the GRANTEE and the STATE, unless the provisions of this CONTRACT provide that mutual agreement is not required. 3. Failure by the GRANTEE to comply with the terms of the (a) PROCEDURAL GUIDE, (b) any legislation applicable to the ACT, (c) this CONTRACT as well as any other grant contracts, specified or general, that GRANTEE has entered into with STATE, may be cause for suspension of all obligations of the STATE unless the STATE determines that such failure was due to no fault of the GRANTEE. In such case, STATE may reimburse GRANTEE for eligible costs properly incurred in performance of this CONTRACT despite non-performance of the GRANTEE. To qualify for such reimbursement, GRANTEE agrees to mitigate its losses to the best of its ability. 4. Any breach of any term, provision, obligation or requirement of this CONTRACT by the GRANTEE shall be a default of this CONTRACT. In the case of any default by GRANTEE, STATE shall be entitled to all remedies available under law and equity, including but not limited to: a) Specific Performance; b) Return of all GRANT MONIES; c) Payment to the STATE of the fair market value of the project property or the actual sales price, whichever is higher; and d) Payment to the STATE of the costs of enforcement of this CONTRACT, including but not limited to court and arbitration costs, fees, expenses of litigation, and reasonable attorney fees. 5. The GRANTEE and the STATE agree that if the GRANT SCOPE includes DEVELOPMENT, final payment may not be made until the work described in the GRANT SCOPE is complete and the GRANT PROJECT is open to the public. F. Budget Contingency Clause 3 DocuSign Envelope ID: 072871 F9-2947-4E86-B553-9A5A3EFD1 63A If funding for any fiscal year is reduced or deleted by the budget act for purposes of this program, the STATE shall have the option to either cancel this contract with no liability occurring to the STATE, or offer a CONTRACT amendment to GRANTEE to reflect the reduced grant amount. This Paragraph shall not require the mutual agreement as addressed in Paragraph E, provision 2, of this CONTRACT. G. Hold Harmless The GRANTEE shall waive all claims and recourse against the STATE including the right to contribution for loss or damage to persons or property arising from, growing out of or in any way connected with or incident to this CONTRACT except claims arising from the concurrent or sole negligence of the STATE, its officers, agents, and employees. 2. The GRANTEE shall indemnify, hold harmless and defend the STATE, its officers, agents and employees against any and all claims, demands, damages, costs, expenses or liability costs arising out of the ACQUISITION, DEVELOPMENT, construction, operation or maintenance of the property described as the project which claims, demands or causes of action arise under California Government Code Section 895.2 or otherwise except for liability arising out of the concurrent or sole negligence of the STATE, its officers, agents, or employees. 3. The GRANTEE agrees that in the event the STATE is named as codefendant under the provisions of California Government Code Section 895 et seq., the GRANTEE shall notify the STATE of such fact and shall represent the STATE in the legal action unless the STATE undertakes to represent itself as codefendant in such legal action in which event the GRANTEE agrees to pay the STATE's litigation costs, expenses, and reasonable attorney fees. 4. The GRANTEE and the STATE agree that in the event of judgment entered against the STATE and the GRANTEE because of the concurrent negligence of the STATE and the GRANTEE, their officers, agents, or employees, an apportionment of liability to pay such judgment shall be made by a court of competent jurisdiction. Neither party shall request a jury apportionment. 5. The GRANTEE shall indemnify, hold harmless and defend the STATE, its officers, agents and employees against any and all claims, demands, costs, expenses or liability costs arising out of legal actions pursuant to items to which the GRANTEE has certified. The GRANTEE acknowledges that it is solely responsible for compliance with items to which it has certified. H. Financial Records 1. The GRANTEE shall maintain satisfactory financial accounts, documents, including loan documents, and all other records for the project and to make them available to the STATE for auditing at reasonable times. The GRANTEE also agrees to retain such financial accounts, documents and records for five years following project 4 DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A termination or issuance of final payment, whichever is later. The GRANTEE shall keep such records as the STATE shall prescribe, including records which fully disclose (a) the disposition of the proceeds of STATE funding assistance, (b) the total cost of the project in connection with such assistance that is given or used, (c) the amount and nature of that portion of the project cost supplied by other sources, and (d) any other such records that will facilitate an effective audit. 3. The GRANTEE agrees that the STATE shall have the right to inspect and make copies of any books, records or reports pertaining to this contract or matters related thereto during regular office hours. The GRANTEE shall maintain and make available for inspection by the STATE accurate records of all of its costs, disbursements and receipts with respect to its activities under this contract. Such accounts, documents, and records shall be retained by the GRANTEE for at least five years following project termination or issuance of final payment, whichever is later. 4. The GRANTEE shall use a generally accepted accounting system. I. Use of Facilities 1. The GRANTEE agrees that the GRANTEE shall operate and maintain the property acquired or developed with the GRANT MONIES, for the duration of the Contract Performance Period. 2. The GRANTEE agrees that, during the Contract Performance Period, the GRANTEE shall use the property acquired or developed with GRANT MONIES under this contract only for the purposes of this grant and no other use, sale, or other disposition or change of the use of the property to one not consistent with its purpose shall be permitted except as authorized by the STATE and the property shall be replaced with property of equivalent value and usefulness as determined by the STATE. 3. The property acquired or developed may be transferred to another entity if the successor entity assumes the obligations imposed under this CONTRACT and with the approval of STATE. 4. Any real Property (including any portion of it or any interest in it) may not be used as security for any debt or mitigation, without the written approval of the STATE provided that such approval shall not be unreasonably withheld as long as the purposes for which the Grant was awarded are maintained. Any such permission that is granted does not make the STATE a guarantor or a surety for any debt or mitigation, nor does it waive the STATE'S rights to enforce performance under the Grant CONTRACT. E DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A 5. All real property, or rights thereto, acquired with GRANT MONIES shall be subject to an appropriate form of restrictive title, rights, or covenants approved by the STATE. If the project property is taken by use of eminent domain, GRANTEE shall reimburse STATE an amount at least equal to the amount of GRANT MONIES received from STATE or the pro -rated full market value of the real property, including improvements, at the time of sale, whichever is higher. 6. If eminent domain proceedings are initiated against GRANTEE, GRANTEE shall notify STATE within 10 days of receiving the complaint. J. Nondiscrimination 1. The GRANTEE shall not discriminate against any person on the basis of sex, race, color, national origin, age, religion, ancestry, sexual orientation, or disability in the use of any property or facility developed pursuant to this contract. 2. The GRANTEE shall not discriminate against any person on the basis of residence except to the extent that reasonable differences in admission or other fees may be maintained on the basis of residence and pursuant to law. 3. All facilities shall be open to members of the public generally, except as noted under the special provisions of this project contract or under provisions of the enabling legislation and/or grant program. K. Severability If any provision of this CONTRACT or the application thereof is held invalid, that invalidity shall not affect other provisions or applications of the CONTRACT which can be given effect without the invalid provision or application, and to this end the provisions of this CONTRACT are severable. L. Liability STATE assumes no responsibility for assuring the safety or standards of construction, site improvements or programs related to the GRANT SCOPE. The STATE'S rights under this CONTRACT to review, inspect and approve the GRANT SCOPE and any final plans of implementation shall not give rise to any warranty or representation that the GRANT SCOPE and any plans or improvements are free from hazards or defects. 2. GRANTEE will secure adequate liability insurance, performance bond, and/or other security necessary to protect the GRANTEE's and STATE'S interest against poor workmanship, fraud, or other potential loss associated with completion of the grant project. M. Assignability E. DocuSign Envelope ID: 072871F9-2947-4E86-B553-9A5A3EFD163A Without the written consent of the STATE, the GRANTEE'S interest in and responsibilities under this CONTRACT shall not be assignable by the GRANTEE either in whole or in part. N. Use of Grant Monies GRANTEE shall not use any grant funds (including any portion thereof) for the purpose of making any leverage loan, pledge, promissory note or similar financial device or transaction, without: 1) the prior written approval of the STATE; and 2) any financial or legal interests created by any such leverage loan, pledge, promissory note or similar financial device or transaction in the project property shall be completely subordinated to this CONTRACT through a Subordination Agreement provided and approved by the STATE, signed by all parties involved in the transaction, and recorded in the County Records against the fee title of the project property. O. Section Headings The headings and captions of the various sections of this CONTRACT have been inserted only for the purpose of convenience and are not a part of this CONTRACT and shall not be deemed in any manner to modify, explain, or restrict any of the provisions of this CONTRACT. P. Waiver Any failure by a party to enforce its rights under this CONTRACT, in the event of a breach, shall not be construed as a waiver of said rights; and the waiver of any breach under this CONTRACT shall not be construed as a waiver of any subsequent breach. GRANTEE By: Signatu Title: City Manager Representative Date: 1,7 1,2 kw?- I STATE OF CALIFORNIA DEPARTMENT OF PARKS AND RECREATION By:1DocuSigned by: ..�,6.a..�... 708FDA4CBD9E41C... Date: 1 /18/2022 i7 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D Exhibit 6 (Grant CONTRACT) State of California - Natural Resources Agency DEPARTMENT OF PARKS AND RECREATION GRANT CONTRACT 2018 Parks Bond Act Per Capita Grant Program GRANTEE City of Poway THE PROJECT PERFORMANCE PERIOD is from July 01, 2018 through June 30, 2024 CONTRACT PERFORMANCE PERIOD is from July 01, 2018 through June 30, 2048 The GRANTEE agrees to the terms and conditions of this Contract, and the State of California, acting through its Director of the Department of Parks and Recreation, pursuant to the State of California, agrees to fund the total State grant amount indicated below. The GRANTEE agrees to complete the GRANT SCOPE(s) as defined in the GRANT SCOPE/Cost Estimate Form or acquisition documentation for the application(s) filed with the State of California. The General and Special Provisions attached are made a part of and incorporated into the Contract. City of Poway By STATE OF CALIFORNIA Gr DEPARTMENT OF PARKS AND RECREATION (Sign ure o Authorized Representative) Title City Manager Date By FjDocuSigned by: Qs k ..t, Date/jE8,LVLLE4IC.- CERTIFICATION OF FUNDING (For State Use Only) CONTRACT NO AMENDMENT NO FISCAL SUPPLIER I.D. PROJECT NO. C9801584 0000039962 18-37-020 AMOUNT ENCUMBERED BY THIS DOCUMENT FUND. $177,952.00 Drought, Water, Cln Air, Cstl Protc, Outdoor Fund PRIOR AMOUNT ENCUMBERED FOR THIS ITEM CHAPTER STATUTE FISCA L YEAR CONTRACT 3790-101-6088 29 18 2021/22 TOTAL AMOUNT ENCUMBERED TO DATE Reporting Structured. Account. ACTIVITY CODE PROJECT / WORK PHASE s $177,952.00 37900091 lAccount/Alt 5432000-5432000000 1 69801 379000001837020 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D I. RECITALS This CONTRACT is entered into between the California Department of Parks and Recreation (hereinafter referred to as "GRANTOR," "DEPARTMENT" or "STATE") and City of Poway (hereinafter referred to as "GRANTEE"). The DEPARTMENT hereby grants to GRANTEE a sum (also referred to as "GRANT MONIES") not to exceed $177,952 , subject to the terms and conditions of this AGREEMENT and the 2018/19 California State Budget, Chapter 29, statutes of 2018, Item number — 3790-101-6088 (appropriation chapter and budget item number hereinafter referred to as "PER CAPITA GRANT'). These funds shall be used for completion of the GRANT SCOPE(S). The Grant Performance Period is from July 01. 2018 to June 30. 2024 II. GENERAL PROVISIONS A. Definitions As used in this CONTRACT, the following words shall have the following meanings: 1. The term "ACT' means the California Drought, Water, Parks Climate, Coastal Protection, and Outdoor Access for All Act of 2018, as referred to in section I of this CONTRACT. 2. The term "APPLICATION" means the individual project APPLICATION packet for a project pursuant to the enabling legislation and/or grant program process guide requirements. 3. The term "DEPARTMENT' or "STATE" means the California Department of Parks and Recreation. 4. The term "DEVELOPMENT' means capital improvements to real property by means of, but not limited to, construction, expansion, and/or renovation, of permanent or fixed features of the property. 5. The term "GRANTEE" means the party described as the GRANTEE in Section I of this CONTRACT. 6. The term "GRANT SCOPE" means the items listed in the GRANT SCOPE/Cost Estimate Form or acquisition documentation found in each of the APPLICATIONS submitted pursuant to this grant. 7. The term "PROCEDURAL GUIDE" means the document identified as the "Procedural Guide for California Drought, Water, Parks, Climate, Coastal Protection, and Outdoor Access For All Act of 2018 Per Capita Program." The DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D PROCEDURAL GUIDE provides the procedures and policies controlling the administration of the grant. B. Project Execution Subject to the availability of GRANT MONIES, the STATE hereby grants to the GRANTEE a sum of money not to exceed the amount stated in Section I of this CONTRACT, in consideration of, and on condition that, the sum be expended in carrying out the purposes as set forth in the scope described in the enabling legislation and referenced in the APPLICATION, Section I of this CONTRACT, and under the terms and conditions set forth in this CONTRACT. The GRANTEE shall assume any obligation to furnish any additional funds that may be necessary to complete the GRANT SCOPE(S). The GRANTEE agrees to submit any change or alteration from the original GRANT SCOPE(S) in writing to the STATE for prior approval. This applies to any and all changes that occur after STATE has approved the APPLICATION. Changes in the GRANT SCOPE(S) must be approved in writing by the STATE. 2. The GRANTEE shall complete the GRANT SCOPE(S) in accordance with the time of the Performance Period set forth in Section I of this CONTRACT, and under the terms and conditions of this CONTRACT. 3. The GRANTEE shall comply with the California Environmental Quality Act (Public Resources Code, Section 21000, et seq., Title 14, California Code of Regulations, Section 15000 et seq.). 4. The GRANTEE shall comply with all applicable current laws and regulations affecting DEVELOPMENT projects, including, but not limited to, legal requirements for construction contracts, building codes, health and safety codes, and laws and codes pertaining to individuals with disabilities, including but not limited to the Americans With Disabilities Act of 1990 (42 U.S.C. §12101 et seq.) and the California Unruh Act (California Civil Code §51 et seq.). C. Project Costs 1. GRANTEE agrees to abide by the PROCEDURAL GUIDE. 2. GRANTEE acknowledges that STATE may make reasonable changes to its procedures as set forth in the PROCEDURAL GUIDE. If STATE makes any changes to its procedures and guidelines, STATE agrees to notify GRANTEE within a reasonable time. D. Project Administration 1. If GRANT MONIES are advanced for DEVELOPMENT projects, the advanced funds shall be placed in an interest bearing account until expended. Interest earned on the advanced funds shall be used on the project as approved by the STATE. If grant monies are advanced and not expended, the unused portion of the 2 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D grant and any interest earned shall be returned to the STATE within 60 days after project completion or end of the Grant Performance Period, whichever is earlier. 2. The GRANTEE shall submit written project status reports within 30 calendar days after the STATE has made such a request. In any event, the GRANTEE shall provide the STATE a report showing total final project expenditures within 60 days of project completion or the end of the grant performance period, whichever is earlier. The Grant Performance Period is identified in Section I of this CONTRACT. 3. The GRANTEE shall make property or facilities acquired and/or developed pursuant to this contract available for inspection upon request by the STATE. E. Project Termination 1. Project Termination refers to the non -completion of a GRANT SCOPE. Any grant funds that have not been expended by the GRANTEE shall revert to the STATE. 2. The GRANTEE may unilaterally rescind this CONTRACT at any time prior to the commencement of the project. The commencement of the project means the date of the letter notifying GRANTEE of the award or when the funds are appropriated, whichever is later. After project commencement, this CONTRACT may be rescinded, modified or amended only by mutual agreement in writing between the GRANTEE and the STATE, unless the provisions of this CONTRACT provide that mutual agreement is not required. 3. Failure by the GRANTEE to comply with the terms of the (a) PROCEDURAL GUIDE, (b) any legislation applicable to the ACT, (c) this CONTRACT as well as any other grant contracts, specified or general, that GRANTEE has entered into with STATE, may be cause for suspension of all obligations of the STATE unless the STATE determines that such failure was due to no fault of the GRANTEE. In such case, STATE may reimburse GRANTEE for eligible costs properly incurred in performance of this CONTRACT despite non-performance of the GRANTEE. To qualify for such reimbursement, GRANTEE agrees to mitigate its losses to the best of its ability. 4. Any breach of any term, provision, obligation or requirement of this CONTRACT by the GRANTEE shall be a default of this CONTRACT. In the case of any default by GRANTEE, STATE shall be entitled to all remedies available under law and equity, including but not limited to: a) Specific Performance; b) Return of all GRANT MONIES; c) Payment to the STATE of the fair market value of the project property or the actual sales price, whichever is higher; and d) Payment to the STATE of the costs of enforcement of this CONTRACT, including but not limited to court and arbitration costs, fees, expenses of litigation, and reasonable attorney fees. 5. The GRANTEE and the STATE agree that if the GRANT SCOPE includes DEVELOPMENT, final payment may not be made until the work described in the GRANT SCOPE is complete and the GRANT PROJECT is open to the public. F. Budget Contingency Clause 3 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D If funding for any fiscal year is reduced or deleted by the budget act for purposes of this program, the STATE shall have the option to either cancel this contract with no liability occurring to the STATE, or offer a CONTRACT amendment to GRANTEE to reflect the reduced grant amount. This Paragraph shall not require the mutual agreement as addressed in Paragraph E, provision 2, of this CONTRACT. G. Hold Harmless 1. The GRANTEE shall waive all claims and recourse against the STATE including the right to contribution for loss or damage to persons or property arising from, growing out of or in any way connected with or incident to this CONTRACT except claims arising from the concurrent or sole negligence of the STATE, its officers, agents, and employees. 2. The GRANTEE shall indemnify, hold harmless and defend the STATE, its officers, agents and employees against any and all claims, demands, damages, costs, expenses or liability costs arising out of the ACQUISITION, DEVELOPMENT, construction, operation or maintenance of the property described as the project which claims, demands or causes of action arise under California Government Code Section 895.2 or otherwise except for liability arising out of the concurrent or sole negligence of the STATE, its officers, agents, or employees. 3. The GRANTEE agrees that in the event the STATE is named as codefendant under the provisions of California Government Code Section 895 et seq., the GRANTEE shall notify the STATE of such fact and shall represent the STATE in the legal action unless the STATE undertakes to represent itself as codefendant in such legal action in which event the GRANTEE agrees to pay the STATE's litigation costs, expenses, and reasonable attorney fees. 4. The GRANTEE and the STATE agree that in the event of judgment entered against the STATE and the GRANTEE because of the concurrent negligence of the STATE and the GRANTEE, their officers, agents, or employees, an apportionment of liability to pay such judgment shall be made by a court of competent jurisdiction. Neither party shall request a jury apportionment. 5. The GRANTEE shall indemnify, hold harmless and defend the STATE, its officers, agents and employees against any and all claims, demands, costs, expenses or liability costs arising out of legal actions pursuant to items to which the GRANTEE has certified. The GRANTEE acknowledges that it is solely responsible for compliance with items to which it has certified. H. Financial Records 1. The GRANTEE shall maintain satisfactory financial accounts, documents, including loan documents, and ail other records for the project and to make them available to the STATE for auditing at reasonable times. The GRANTEE also agrees to retain such financial accounts, documents and records for five years following project 4 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D termination or issuance of final payment, whichever is later. 2. The GRANTEE shall keep such records as the STATE shall prescribe, including records which fully disclose (a) the disposition of the proceeds of STATE funding assistance, (b) the total cost of the project in connection with such assistance that is given or used, (c) the amount and nature of that portion of the project cost supplied by other sources, and (d) any other such records that will facilitate an effective audit. 3. The GRANTEE agrees that the STATE shall have the right to inspect and make copies of any books, records or reports pertaining to this contract or matters related thereto during regular office hours. The GRANTEE shall maintain and make available for inspection by the STATE accurate records of all of its costs, disbursements and receipts with respect to its activities under this contract. Such accounts, documents, and records shall be retained by the GRANTEE for at least five years following project termination or issuance of final payment, whichever is later. 4. The GRANTEE shall use a generally accepted accounting system. I. Use of Facilities 1. The GRANTEE agrees that the GRANTEE shall operate and maintain the property acquired or developed with the GRANT MONIES, for the duration of the Contract Performance Period. 2. The GRANTEE agrees that, during the Contract Performance Period, the GRANTEE shall use the property acquired or developed with GRANT MONIES under this contract only for the purposes of this grant and no other use, sale, or other disposition or change of the use of the property to one not consistent with its purpose shall be permitted except as authorized by the STATE and the property shall be replaced with property of equivalent value and usefulness as determined by the STATE. 3. The property acquired or developed may be transferred to another entity if the successor entity assumes the obligations imposed under this CONTRACT and with the approval of STATE. 4. Any real Property (including any portion of it or any interest in it) may not be used as security for any debt or mitigation, without the written approval of the STATE provided that such approval shall not be unreasonably withheld as long as the purposes for which the Grant was awarded are maintained. Any such permission that is granted does not make the STATE a guarantor or a surety for any debt or mitigation, nor does it waive the STATE'S rights to enforce performance under the Grant CONTRACT. 5 DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D 5. All real property, or rights thereto, acquired with GRANT MONIES shall be subject to an appropriate form of restrictive title, rights, or covenants approved by the STATE. If the project property is taken by use of eminent domain, GRANTEE shall reimburse STATE an amount at least equal to the amount of GRANT MONIES received from STATE or the pro -rated full market value of the real property, including improvements, at the time of sale, whichever is higher. 6. If eminent domain proceedings are initiated against GRANTEE, GRANTEE shall notify STATE within 10 days of receiving the complaint. J. Nondiscrimination 1. The GRANTEE shall not discriminate against any person on the basis of sex, race, color, national origin, age, religion, ancestry, sexual orientation, or disability in the use of any property or facility developed pursuant to this contract. 2. The GRANTEE shall not discriminate against any person on the basis of residence except to the extent that reasonable differences in admission or other fees may be maintained on the basis of residence and pursuant to law. 3. All facilities shall be open to members of the public generally, except as noted under the special provisions of this project contract or under provisions of the enabling legislation and/or grant program. K. Severability If any provision of this CONTRACT or the application thereof is held invalid, that invalidity shall not affect other provisions or applications of the CONTRACT which can be given effect without the invalid provision or application, and to this end the provisions of this CONTRACT are severable. L. Liability STATE assumes no responsibility for assuring the safety or standards of construction, site improvements or programs related to the GRANT SCOPE. The STATE'S rights under this CONTRACT to review, inspect and approve the GRANT SCOPE and any final plans of implementation shall not give rise to any warranty or representation that the GRANT SCOPE and any plans or improvements are free from hazards or defects. 2. GRANTEE will secure adequate liability insurance, performance bond, and/or other security necessary to protect the GRANTEE's and STATE'S interest against poor workmanship, fraud, or other potential loss associated with completion of the grant project. M. Assignability L DocuSign Envelope ID: 9C932541-4D58-492B-9EBF-5EBB7F7B3C9D Without the written consent of the STATE, the GRANTEE'S interest in and responsibilities under this CONTRACT shall not be assignable by the GRANTEE either in whole or in part. N. Use of Grant Monies GRANTEE shall not use any grant funds (including any portion thereof) for the purpose of making any leverage loan, pledge, promissory note or similar financial device or transaction, without: 1) the prior written approval of the STATE; and 2) any financial or legal interests created by any such leverage loan, pledge, promissory note or similar financial device or transaction in the project property shall be completely subordinated to this CONTRACT through a Subordination Agreement provided and approved by the STATE, signed by all parties involved in the transaction, and recorded in the County Records against the fee title of the project property. O. Section Headings The headings and captions of the various sections of this CONTRACT have been inserted only for the purpose of convenience and are not a part of this CONTRACT and shall not be deemed in any manner to modify, explain, or restrict any of the provisions of this CONTRACT. P. Waiver Any failure by a party to enforce its rights under this CONTRACT, in the event of a breach, shall not be construed as a waiver of said rights; and the waiver of any breach under this CONTRACT shall not be construed as a waiver of any subsequent breach. GRANTEE ri By:� Signatu orized Representative Title: City Manager Date: 17 Zv L-2-9a STATE OF CALIFORNIA DEPARTMENT OF PARKS AND RECREATION By: 5LuSigned by: —6A..>_.a.. a—,, 708FDMUD9E41 C... Date: 1 /18/2022 7 TRUE COPY CERTIFICATION (Government Code 27361.7) C A -- Place of Execution I certify under penalty of perjury that this material is a true copy of the original material contained in this document. 05 iD630- D V Uk Date Signature of Declarant MdV16 Saes Type or Print Name Rec.Form #R9.1 (Revised 11-15-10)