HomeMy WebLinkAboutR-2006-001 Surplus Van Pool VehiclesRESOLUTION NO. R-2006-01
A RESOLUTION declaring four (4) 1990 Ford Vanpool vans to be surplus to the needs of the
City of Yakima and the Transit Department, and authorizing the City
Manager to execute the Agreements for transfer of ownership of these
vehicles through the Van Grant Program to the Southeast Yakima
Community Center, the Provident Horizon Group, Templo Bautista de
Yakima and Stone Church.
WHEREAS, the City of Yakima owns four (4) used 1990 Ford Vanpool vans with
vehicle identification numbers 1FBJS31MXLHA61920 to Stone Church, 1FBJS31M1LHA61921 to
Templo Bautista de Yakima, 1FBJS31MOLHA61926 to the Provident Horizon Group,
1FBJS31M2LHA61927 to the Southeast Yakima Community Center; for which the City and the
Transit Department have no immediate or foreseeable use and which are surplus to the needs
of the City and the Transit Department; and
WHEREAS, the City Council finds that it would be in the best interest of the City to sell
and transfer said vehicles to the Southeast Yakima Community Center, the Provident Horizon
Group, Templo Bautista de Yakima and Stone Church through the Van Grant Program for
$500.00, now, therefore,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF YAKIMA:
The City Council hereby declares the aforementioned 1990 Ford Vanpool Vans to be
surplus to the needs of the City of Yakima and the Transit Department, and the City Manager
is hereby authorized and directed to sell and transfer said vehicles to the Southeast Yakima
Community Center, the Provident Horizon Group, Templo Bautista and Stone Church.
ADOPTED BY THE CITY COUNCIL this 3rd day of „yuary, 2006
ATTEST:
City Clerk
(1k)res-fire dept -fire pumper truck- surplus 02 -pm
Mayor
Memo
TO: Interested Agencies and Organizations
FROM: Karen Allen, Marketing and Program Administration
SUBJECT: Application for Surplus Vans
DATE: November 15, 2005
The Yakima City Council Transit Committee has approved our surplus van grant
program. In this program, four 15 passenger vans will be made available to
community agencies to enhance transportation service to residents of the City of
Yakima and the surrounding area. These vehicles, which were earmarked for
retirement and scheduled for auction; instead will be awarded to eligible non-
profit and government organizations serving clients with unmet transportation
needs in the Yakima area. It is anticipated that the services provided with these
vans; such as transportation at times when Yakima Transit bus service is not in
operation or to areas not reached by the Yakima Transit bus routes, and the
provision of transportation in lieu of Dial -A -Ride services will result in a financial
savings to the City. It is further anticipated that such savings will exceed the
dollar value that would be realized if the vans were sold at auction. The sum of
$500 is not reflective of the market value of the van but is a nominal fee that will
be assessed to offset administrative and transfer fees and will be charged to the
grantee upon award of the grant.
Attached are an application and other information that describes how to apply for one
of these vehicles. Only one vehicle will be awarded per organization. Please note:
Completed applications must be received by the City of Yakima, Clerks Office,
129 No. 2" St., no later than 2:OOp.m. Wednesday, December 7, 2005. The
attached application packet provides specific details on the application process and
schedule.
Interested applicants are invited to attend a Pre -Application Workshop that will
be held at 2:00 p.in. Wednesday, November 30, 2005 in the Training Room at
the City of Yakima Public Works facility located at 2301 Fruitvale Blvd, in
Yakima. This voluntary workshop will provide applicants an opportunity to ask
questions about the application process, selection criteria, van maintenance,
mileage and upkeep. The vehicles will be available for inspection after the
workshop.
If you have any questions about this program, please contact either Karen Allen
at (509) 576-6423, email at kallen@ci.yakima.wa.us ci.yakima.wa.us , or Gary Pira at (509)576-
6422, e-mail gpiraOci.yakima.wa.us.
2004 Vehicle Transfer Packet
Yakima Transit
Rules/Requirements and Selection Criteria for
Surplus Vans
Background
The Yakima City Council Transit Committee has approved the surplus van grant program. In
the program, four 15 passenger vans will be made available to community agencies to enhance
transportation service to residents of the City of Yakima and the surrounding area. These
vehicles, which were earmarked for retirement and scheduled for auction, instead will be
awarded to eligible non-profit and government organizations serving clients with unmet
transportation needs in the Yakima area. The opportunity to be awarded one of these vans is
not intended to be a gift. It is intended that these vans will be used to supplement Yakima
Transit's fixed route and Dial -A -Ride services to provide greater transportation opportunities
to the citizens of Yakima and to financially benefit Yakima through cost savings.
This packet contains the application, rules/requirements and selection criteria developed by
Yakima Transit staff to implement that plan.
Vehicle Descriptions
Four surplus vehicles will be granted as described below:
• Four 1990 15 -passenger vans (no wheelchair lifts). Ford E350, diesel engines, automatic
transmissions, with between 150,521 —171,645 miles.
Vehicles will be available for inspection after the Pre -Application Workshop, which will be
held Wednesday, November 30, 2005 at 2:00 p.m. in City of Yakima Public Works Training
Room, 2301 Fruitvale Blvd. in Yakima. Call Yakima Transit at 509-575-6175 for transit or
driving directions. No reservation for the workshop is necessary. Attendance at the Pre -
Application Workshop is voluntary.
Eligibility
All non-profit organizations and agencies (with 501(c) 3 status), which serve residents of the
City of Yakima and/or areas of Yakima County immediately surrounding the City of Yakima
are eligible. Questions about eligibility, limits of the surrounding area and other
questions about the program should be directed to: Karen Allen, Marketing and
Program Administrator at 509-576-6423, or Gary Pira, Transit Planner, at 509-576-6422.
Other Rules and Requirements
• Vehicles must be used for a transportation -related purpose for residents who live within the
City of Yakima or the immediate area surrounding the City of Yakima.
• Only one vehicle will be awarded per agency/organization per year.
2004 Vehicle Transfer Packet
• Application must clearly designate the primary applicant who will be named as buyer on
vehicle title, if selected as a recipient.
• Applicant must certify they have the financial and management capacity to insure granted
vehicle, if selected as a recipient.
• Applicants must certify they have the financial and management capacity to maintain
vehicles in good working condition for the remaining useful life of said vehicle.
• Applicants must provide a copy of the 501(c) 3 non-profit certification, if applicable.
• Successful applicants will be required to sign an agreement relating to the exchange of
vehicles for transportation -related services which will be the consideration for the
transaction. A sample agreement is included in this packet.
• Applicants must track ridership, hours and miles of service and provide a report to Yakima
Transit at the end of the first year of service.
• Applicants shall only provide transportation to their clients, members, guest or other similar
users with vans supplied under this program. They shall not provide transportation to the
general public or individuals in no way affiliated with their group.
• The sum of $500 is not reflective of the market value of the van but is a nominal fee
assessed to offset administrative and transfer fees and will be charged to the grantee upon
award of the grant.
• Applicants shall not use the vehicle for assisting a campaign for election or for the
promotion of or opposition to any ballot proposition.
Application Schedule
November 30, 2005
December 7, 2005
December 16, 2005
December 21, 2005
Pre -Application Workshop
Deadline for submitting applications
Review and scoring of applications by Selection Team
Announcement of vehicle awards
Application Submittal
A paper copy of the application is attached. The application is also available on Yakima
Transit's website: www.yakimatransit.org or via e-mail from Karen Allen or Gary Pira at the
e-mail addresses given above.
Applications must be received at the City of Yakima, Clerks Office, 129 No. 2"d St. no
later than 2:00 p.m. December 7, 2005. Applications should be sent or delivered to:
City of Yakima, Clerks Office
129 No. 2"d Street
Yakima, WA 98901
2004 Vehicle Transfer Packet
Selection Criteria Summary
The selection process is competitive and involves review and evaluation using the criteria
identified below. In addition to these specific criteria other criteria such as geographic equity
and diversity in population groups served will be used as balancing factors in making final
selections.
CRITERIA:
WEIGHT:
1. Demonstrated Community Benefit
2. Total Number of Trips Provided
3. Clarity and Quality of Application
4. Coordination of Services
5. Ability of Organization to Maintain Service
Selection Criteria
50%
20%
15%
10%
5%
1. Demonstrated Community Benefit
Explain clearly the scope and nature of your agency's transportation need and what data
you have to back up that need. Explain how granting your application would serve an
unmet public transportation need in the City of Yakima and the surrounding area. Include
what service you currently utilize, what other options are available to your organization and
how your program will meet that need and coordinate with other programs to get maximum
use.
2. Total Number of Trips Provided
Clearly define and document the number of trips to be provided annually. Give the best
estimate you can as to where the trips would go.
3. Clarity and Quality of Application
Applications will be rated on content, clarity, presentation and quality of application
proposal — based on legibility, completeness, provision of data and clear definition of
transportation needs and planned vehicle use.
4. Coordination of Service
Describe how your current and proposed service coordinates with other transportation
services in the area to ensure broad community benefit. Describe why existing Yakima
Transit services cannot or do not meet the need.
5. Ability of Organization to Maintain Service
Describe how the proposed transportation program will be maintained and funded and how
the organization will manage the program.
2004 Vehicle Transfer Packet
SAMPLE
AGREEMENT RELATING TO THE EXCHANGE
OF VEHICLE FOR TRANSIT RELATED SERVICES
THIS AGREEMENT between the City of Yakima, Transit Division (commonly known
as and hereinafter called "Yakima Transit"), and
, hereinafter referred to as the "NAME OF
TRANSFEREE") as follows:
In consideration of the mutual promises of the parties, it is hereby agreed as follows:
1. Yakima Transit shall provide to the NAME OF TRANSFEREE the following described
vehicle:
Make:
Year:
Model:
VIN:
2. NAME OF TRANSFEREE shall provide the following services in consideration for the
aforementioned vehicle: To provide enhanced transportation services for residents who
live within the City of Yakima or the immediate surrounding area as described in Sec.2,
description of proposed vehicles use, in the application. Use of the vehicle for other
purposes is prohibited. If NAME OF TRANSFEREE does not use the vehicle for the
above transportation service for a period of one (I) quarter, NAME OF TRANSFEREE
shall forfeit the vehicle within thirty days and the vehicle shall be returned to Yakima
Transit.
3. Yakima Transit is selling NAME OF TRANSFEREE the aforementioned vehicle for
the amount of $500.00 AS IS, WHERE IS, and WITH ALL FAULTS and WITHOUT
RECOURSE regarding the condition of the aforementioned vehicle. Yakima Transit
makes NO EXPRESSED or IMPLIED WARRANTIES of MERCHANTABILITY; NO
EXPRESS or IMPLIED WARRANTIES of FITNESS; and no EXPRESS or IMPLIED
WARRANTIES or GUARANTEES of any other kind regarding the aforementioned
vehicle.
4. The parties to this Agreement agree that Yakima Transit shall have no liabilities of any
sort arising from or related to the vehicle or vehicles covered by this Agreement.
NAME OF TRANSFEREE and any successor shall defend, indemnify and hold
harmless the City of Yakima, Yakima Transit, their officers, agents and employees
from any claims or suits at law or equity, costs and/or demands of any sort, including
reasonable attorneys' fees, arising out of or related to this Agreement, the vehicle or
vehicles covered by this Agreement, or any use by any person of such vehicles.
2004 Vehicle Transfer Packet
5. If NAME OF TRANSFEREE sells, donates or transfers any vehicle or vehicles covered
by this Agreement, NAME OF TRANSFEREE shall require the subsequent transferee
to execute a binding agreement to defend, indemnify and hold the City of Yakima,
Yakima Transit and its officers, agents and employees harmless as set out in the
preceding paragraph.
6. NAME OF TRANSFEREE shall be responsible for all licensing, permits and insurance
of the aforementioned vehicle. Proof of insurance acceptable to Yakima Transit shall
be provided to Yakima Transit as an express condition of delivery of the
aforementioned vehicle to NAME OF TRANSFEREE. NAME OF TRANSFEREE
shall promptly carry out all steps necessary to transfer vehicle title to it from the City of
Yakima and/or Yakima Transit.
7. NAME OF TRANSFEREE shall provide to Yakima Transit a report at the end of one
(1) calendar year, containing vehicle odometer readings, number of passengers carried,
and description of use of vehicle. Information shall be submitted to Karen Allen,
Yakima Transit, 2301 Fruitvale Blvd, Yakima, WA 98902 or faxed to 509-576-6414.
8. NAME OF TRANSFEREE will assure they provide transportation services only to
their clients, members, guests or other similar users, not the general public or
individuals in no way affiliated with their group, with vans supplied by this program.
NAME OF TRANSFEREE will not use the vehicle for assisting a campaign for
election or for the promotion of or opposition to any ballot proposition.
9. NAME OF TRANSFEREE represents and warrants that it does not discriminate on the
basis of race, color, creed, sex, disability, age or national origin and that the vehicles
transferred herein will not be used for any illegal, improper or immoral purpose. The
use of the vehicle for any illegal, improper or immoral purpose shall result in forfeiture
of the vehicle within thirty days and NAME OF TRANSFEREE shall return the vehicle
to Yakima Transit.
10. NAME OF TRANSFEREE specifically authorizes and consents to Yakima Transit's
use of any remedy provided by law, including the right of replevin pursuant to RCW
7.64 et seq., to reclaim the subject vehicle in the event NAME OF TRANSFEREE
breaches this Agreement.
11. This Agreement shall be governed by and construed in accordance with the laws of the
State of Washington. The venue for any action to enforce or interpret this Agreement
shall lie in the Superior Court of Washington for Yakima County.
12. The person executing this Agreement on behalf of NAME OF TRANSFEREE
represents and warrants that he/she has been fully authorized by NAME OF
TRANSFEREE to execute this Agreement on its behalf and to legally bind NAME OF
TRANSFEREE to all the terms and obligations of this Agreement.
2004 Vehicle Transfer Packet
DATED:
City of Yakima, Transit Division
By:
Title:
ATTEST:
Transferee
By:
Title:
ATTEST:
Witness
2004 Vehicle Transfer Packet
YAKIMA TRANSIT
Application for Surplus Vans
Section 1: General Information
1. Name of Primary Applicant
Agency/ Organization:
2. Mailing Address:
3. Contact Person/Telephone:
4. Partner
Agency/Organization:
5. Partner
Agency/Organization:
6. Type of Applicant(s) (check all that apply):
Public Agency School/Daycare Place of Worship
Community Service Senior Center/ Other, please specify
Organization Convalescent Center
Section 2: Description of Proposed Vehicle Use
1. Describe the community transportation problem you are proposing to solve with this
vehicle and the benefit you want to achieve. Include in your answer the population you
will serve, the area of the City of Yakima or the immediate surrounding area you will
serve, type of service you will provide, purpose of the transportation, extent of vehicle
use and any other information you want us to know. (Attach an additional sheet, if
needed.)
2004 Vehicle Transfer Packet
2. How many passenger trips do you expect to carry over the course of the next year? For
the purposes of this application, a passenger trip is defined as a round trip for one
person i.e. to/from their destination. Please show how you arrived at your estimate and
describe the basis of your projection.
The hypothetical example below illustrates the type of information we are looking for
in this question. In this example, the van would be utilized to support several programs
within one organization.
Example
Our group expects to utilize the van to provide 2448 passenger trips over the next year
based on the following:
• 5 people to place of employment each workday = 5 people x 250 work days = 1250
Basis: current number of developmentally disabled clients lacking daily transportation
to work
• 20 seniors on field trip one Saturday per month = 20 people x 12 field trips = 240
Basis: planned new program if a vehicle is available.
• 4 people to place of worship each week = 4 people x 52 weeks = 208
Basis: average number of people carried last year in old van.
• 150 low-income children to a week-long summer camp in June = 150 people x
5 days = 750
Basis: attendance at last year's camp.
3. Please describe the profile of the passengers you anticipate serving with this vehicle.
Profiles include, but are not limited to, persons with disabilities, senior citizens, persons
with low income, at risk youth, etc...
4. Please describe your service area.
2004 Vehicle Transfer Packet
5. a) Please describe how your organization coordinates transportation efforts with other
community programs.
b) Please describe how your organization coordinates transportation needs with other
transportation providers, including Yakima Transit.
6. What method of transportation does your program currently use to meet your
organization's transportation needs?
7. a) To what extent does existing Yakima Transit bus and Dial -A -Ride service meet your
organization's transportation needs?
b) If current Yakima Transit service does not work for your organization, why not?
8. a) Will the vehicle be used to expand service (such as, establishing a new service,
increasing the frequency of an existing service, etc.), to replace an existing service or
both?
Expand Service Replace Existing Both
b) If the vehicle will be used to expand service, estimate the number of new trips that
will be provided and/or explain how the vehicle will be used to expand service. (Attach
additional sheets if necessary)
c) If the vehicle will replace existing service, please state the age and mileage of your
current vehicle(s) and estimate the number of trips that will be provided with the
vehicle.
9. Is this application in coordination with any other agencies? Yes No
If yes:
a) List the name of the primary applicant who will be named as buyer on vehicle
title if selected as a vehicle recipient, and
b) Briefly explain how the use of the vehicle will be divided among the
agencies/ organizations involved. (All participating agencies/organizations are
required to sign the certification and should also be identified on Page 1 of this
application).
2004 Vehicle Transfer Packet
Section 3: Certification
I certify that, to the best of my knowledge, the information in this application is true and
accurate and that this agency/organization has the necessary financial and managerial
capability to adequately operate, maintain and insure the vehicle for which this
application is being made.
Signature of Lead Agency/Organization
Board Chair/Executive
Officer:
Typed
Name/Title:
Date:
Signature of Partner Agency/Organization
Board Chair/Executive
Officer:
Typed
Name/Title:
Date:
Signature of Partner Agency/Organization
Board Chair/Executive
Officer:
Typed
Name/Title:
Date:
2004 Vehicle Transfer Packet
I I'EM TITLE:
BUSINESS OF THE CITY COUNCIL
YAKIMA, WASHINGTON
AGENDA STATEMENT
Item No. 1 D
For Meeting Of 01/03/06
A resolution declaring four (4) 1990 Ford Vanpool Vans to be surplus
to the needs of the City of Yakima and the Transit Department and
authorizing the City Manager to execute the Agreements for transfer
of the vans through the Van Grant Program to four (4) selected non-
profit community entities.
SUBMII"IED BY: Director of Public Works, Chris Waarvick
CONTACT PERSON/ TELEPHONE: Karen Allen, Marketing and Program Administrator,
576-6423
SUMMARY EXPLANATION:
The Yakima Transit Division has four (4) 1990 Ford Vanpool vans with between 150,500 to
171,600 miles on them that have been replaced and are excess to the Division's Vanpool needs.
A Van Grant Program was developed with City Council Transit Committee approval to help
meet currently unserved transportation needs in the Yakima area; such as transportation at
times when Yakima Transit bus service is not in operation or to areas not reached by Yakima
Transit, and the provision of transportation in lieu of Dial -A -Ride services which will result in
financial savings to the City. The vans will be used by the non -profits for purposes stated in
each application. A progress report is required to document the success in achieving the goals
stated by each applicant. The Division has identified through competitive application process
four (4) local '501(C)3' non-profit entities to purchase a van for a $500.00 fee. This fee offsets the
administrative and transfer fees incurred by the City. Funds real»ed from the sale and transfer
will be credited to the Transit Division's Vanpool equipment replacement account (Capital
Fund).
Resolution X Ordinance Contract X Other (Specify)
Funding Source N/A
APPROVED FOR SUBMITTAL:
STAFF RECOMMENDATION: Adopt resolution.
City Manager
BOARD/COMMISSION RECOMMENDATION: The Van Grant Program and community
entities selected to receive a van under the program have been approved by the Yakima City
Council Transit Committee.
COUNCIL ACTION:
AGREEMENT RELATING TO THE EXCHANGE
OF VEHICLE FOR TRANSIT RELATED SERVICES
THIS AGREEMENT between the City of Yakima, Transit Division (commonly known
as and hereinafter called "Yakima Transit"), and
S61.01.ece.S *kle.iArtka...Qornrnoni Citilkerhereinafter referred to as the "NAME OF
TRANSFEREE") as follows:
In consideration of the mutual promises of the parties, it is hereby agreed as follows:
1. Yakima Transit shall provide to the NAME OF TRANSFEREE the following described
vehicle:
Make: cor'G\.
Year: 1,°1c)(0
2. NAME OF TRANSFEREE shall provide the following services in consideration for the
aforementioned vehicle: To provide enhanced transportation services for residents who
live within the City of Yakima or the immediate surrounding area as described in Sec.2,
description of proposed vehicles use, in the application. Use of the vehicle for other
purposes is prohibited. If NAME OF TRANSFEREE does not use the vehicle for the
above transportation service for a period of one (1) quarter, NAME OF TRANSFEREE
shall forfeit the vehicle within thirty days and the vehicle shall be returned to Yakima
Transit.
3. Yakima Transit is selling NAME OF TRANSFEREE the aforementioned vehicle for
the amount of $500.00 AS IS, WHERE IS, and WITH ALL FAULTS and WITHOUT
RECOURSE regarding the condition of the aforementioned vehicle. Yakima Transit
makes NO EXPRESSED or IMPLIED WARRANTIES of MERCHANTABILITY; NO
EXPRESS or IMPLIED WARRANTIES of FITNESS; and no EXPRESS or IMPLIED
WARRANTI FS or GUARANTEES of any other kind regarding the aforementioned
vehicle.
4. The parties to this Agreement agree that Yakima Transit shall have no liabilities of any
sort arising from or related to the vehicle or vehicles covered by this Agreement.
NAME OF TRANSFEREE and any successor shall defend, indemnify and hold
harmless the City of Yakima, Yakima Transit, their officers, agents and employees
from any claims or suits at law or equity, costs and/or demands of any sort, including
reasonable attorneys' fees, arising out of or related to this Agreement, the vehicle or
vehicles covered by this Agreement, or any use by any person of such vehicles.
2004 Vehicle Transfer Packet
5. If NAME OF TRANSFEREE sells, donates or transfers any vehicle or vehicles covered
by this Agreement, NAME OF TRANSFEREE shall require the subsequent transferee
to execute a binding agreement to defend, indemnify and hold the City of Yakima,
Yakima Transit and its officers, agents and employees harmless as set out in the
preceding paragraph.
6. NAME OF TRANSFEREE shall be responsible for all licensing, permits and insurance
of the aforementioned vehicle. Proof of insurance acceptable to Yakima Transit shall
be provided to Yakima Transit as an express condition of delivery of the
aforementioned vehicle to NAME OF TRANSFEREE. NAME OF TRANSFEREE
shall promptly carry out all steps necessary to transfer vehicle title to it from the City of
Yakima and/or Yakima Transit.
7. NAME OF TRANSFEREE shall provide to Yakima Transit a report at the end of one
(1) calendar year, containing vehicle odometer readings, number of passengers carried,
and description of use of vehicle. Information shall be submitted to Karen Allen,
Yakima Transit, 2301 Fruitvale Blvd, Yakima, WA 98902 or faxed to 509-576-6414.
8. NAME OF TRANSFEREE will assure they provide transportation services only to
their clients, members, guests or other similar users, not the general public or
individuals in no way affiliated with their group, with vans supplied by this program.
NAME OF TRANSFEREE will not use the vehicle for assisting a campaign for
election or for the promotion of or opposition to any ballot proposition.
9. NAME OF TRANSFEREE represents and warrants that it does not discriminate on the
basis of race, color, creed, sex, disability, age or national origin and that the vehicles
transferred herein will not be used for any illegal, improper or immoral purpose. The
use of the vehicle for any illegal, improper or immoral purpose shall result in forfeiture
of the vehicle within thirty days and NAME OF TRANSFEREE shall return the vehicle
to Yakima Transit.
10. NAME OF TRANSFEREE specifically authorizes and consents to Yakima Transit's
use of any remedy provided by law, including the right of replevin pursuant to RCW
7.64 et seq., to reclaim the subject vehicle in the event NAME OF TRANSFEREE
breaches this Agreement.
11. This Agreement shall be governed by and construed in accordance with the laws of the
State of Washington. The venue for any action to enforce or interpret this Agreement
shall lie in the Superior Court of Washington for Yakima County.
12. The person executing this Agreement on behalf of NAME OF TRANSFEREE
represents and warrants that he/she has been fully authorized by NAME OF
TRANSFEREE to execute this Agreement on its behalf and to legally bind NAME OF
TRANSFEREE to all the terms and obligations of this Agreement.
2004 Vehicle Transfer Packet
DATED: ,/3104
City of Yakima, Transit Division
By:
Title:'
ATTEST:
Transferee
ATTEST:
City of Yakima
City Manager
ATTEST:
City Clerk
CITY CONTRACFNO. � V/�/ r�S
RESOLUTION NO• isqG�OvID O i
2004 Vehicle Transfer Packet
AGREEMENT RELATING TO THE EXCHANGE
OF VEHICLE FOR TRANSIT RELATED SERVICES
THIS AGREEMENT between the City of Yakima, Transit Division (commonly known
as and hereinafter called "Yakima Transit"), and
ir\-e-- C.ielL c "'" , hereinafter referred to as the "NAME OF
TRANSFEREE") as follows:
In consideration of the mutual promises of the parties, it is hereby agreed as follows:
1. Yakima Transit shall provide to the NAME OF TRANSFEREE the following described
vehicle:
Make: - c rd l
Year: 1 '110
Model: \a/vttooL-
VIN: '1_fB �53'i- Iuk)CL\- Pr(019 20
2. NAME OF TRANSFEREE shall provide the following services in consideration for the
aforementioned vehicle: To provide enhanced transportation services for residents who
live within the City of Yakima or the immediate surrounding area as described in Sec.2,
description of proposed vehicles use, in the application. Use of the vehicle for other
purposes is prohibited. If NAME OF TRANSFEREE does not use the vehicle for the
above transportation service for a period of one (1) quarter, NAME OF TRANSFEREE
shall forfeit the vehicle within thirty days and the vehicle shall be returned to Yakima
Transit.
3. Yakima Transit is selling NAME OF TRANSFEREE the aforementioned vehicle for
the amount of $500.00 AS IS, WHERE IS, and WITH ALL FAULTS and WITHOUT
RECOURSE regarding the condition of the aforementioned vehicle. Yakima Transit
makes NO EXPRESSED or IMPLIED WARRANTIES of MERCHANTABILITY; NO
EXPRESS or IMPLIED WARRANTIES of FITNESS; and no EXPRESS or IMPLIED
WARRANTIES or GUARANTEES of any other kind regarding the aforementioned
vehicle.
4. The parties to this Agreement agree that Yakima Transit shall have no liabilities of any
sort arising from or related to the vehicle or vehicles covered by this Agreement.
NAME OF TRANSFEREE and any successor shall defend, indemnify and hold
harmless the City of Yakima, Yakima Transit, their officers, agents and employees
from any claims or suits at law or equity, costs and/or demands of any sort, including
reasonable attorneys' fees, arising out of or related to this Agreement, the vehicle or
vehicles covered by this Agreement, or any use by any person of such vehicles.
2004 Vehicle Transfer Packet
5. If NAME OF TRANSNEREE sells, donates or transfers any vehicle or vehicles covered
by this Agreement, NAME OF TRANSFEREE shall require the subsequent transferee
to execute a binding agreement to defend, indemnify and hold the City of Yakima,
Yakima Transit and its officers, agents and employees harmless as set out in the
preceding paragraph.
6. NAME OF TRANSFEREE shall be responsible for all licensing, permits and insurance
of the aforementioned vehicle. Proof of insurance acceptable to Yakima Transit shall
be provided to Yakima Transit as an express condition of delivery of the
aforementioned vehicle to NAME OF TRANSFEREE. NAME OF TRANSFEREE
shall promptly carry out all steps necessary to transfer vehicle title to it from the City of
Yakima and/or Yakima Transit.
7. NAME OF TRANSFEREE shall provide to Yakima Transit a report at the end of one
(1) calendar year, containing vehicle odometer readings, number of passengers carried,
and description of use of vehicle. Information shall be submitted to Karen Allen,
Yakima Transit, 2301 Fruitvale Blvd, Yakima, WA 98902 or faxed to 509-576-6414.
8. NAME OF TRANSNEREE will assure they provide transportation services only to
their clients, members, guests or other similar users, not the general public or
individuals in no way affiliated with their group, with vans supplied by this program.
NAME OF TRANSFEREE will not use the vehicle for assisting a campaign for
election or for the promotion of or opposition to any ballot proposition.
9. NAME OF TRANSFEREE represents and warrants that it does not discriminate on the
basis of race, color, creed, sex, disability, age or national origin and that the vehicles
transferred herein will not be used for any illegal, improper or immoral purpose. The
use of the vehicle for any illegal, improper or immoral purpose shall result in forfeiture
of the vehicle within thirty days and NAME OF TRANSFEREE shall return the vehicle
to Yakima Transit.
10. NAME OF TRANSFEREE specifically authorizes and consents to Yakima Transit's
use of any remedy provided by law, including the right of replevin pursuant to RCW
7.64 et seq., to reclaim the subject vehicle in the event NAME OF TRANSFEREE
breaches this Agreement.
11. This Agreement shall be governed by and construed in accordance with the laws of the
State of Washington. The venue for any action to enforce or interpret this Agreement
shall lie in the Superior Court of Washington for Yakima County.
12. The person executing this Agreement on behalf of NAME OF TRANSFEREE
represents and warrants that he/she has been fully authorized by NAME OF
TRANSFEREE to execute this Agreement on its behalf and to legally bind NAME OF
TRANSFEREE to all the terms and obligations of this Agreement.
2004 Vehicle Transfer Packet
DATED: 1/ `f I 0 LD
City of Yakima, Transit Division
By: :
Title: ll�PJ1�
By: /\
Title: 4 v►'1 2 G t' �!M-�2 II�II'�. C �✓
ATTEST:
Transferee
ATTEST:
City of Yakima
By:
Cit -7 Manager
ATTEST:
y -Th
City Clerk
CITY CONTRAC f NO: AtV 1,0 D SIJ
RESOLUTION NO:
2004 Vehicle Transfer Packet
AGREEMENT RELATING TO THE EXCHANGE
OF VEHICLE FOR TRANSIT RELATED SERVICES
THIS AGREEMENT between the City of Yakima, Transit Division (commonly known
as and hereinafter called "Yakima Transit"), and
v Si �� hereinafter referred to as the "NAME OF
TRANSFEREE") as follows:
In consideration of the mutual promises of the parties, it is hereby agreed as follows:
1. Yakima Transit shall provide to the NAME OF TRANSFEREE the following described
vehicle:
Make: ` t.; `r'd
Year: 199 0
Model: V?Aft . U—
VIN: 17.5 (¢i-92--�.
2. NAME OF TRANSFEREE shall provide the following services in consideration for the
aforementioned vehicle: To provide enhanced transportation services for residents who
live within the City of Yakima or the immediate surrounding area as described in Sec.2,
description of proposed vehicles use, in the application. Use of the vehicle for other
purposes is prohibited. If NAME OF TRANSFEREE does not use the vehicle for the
above transportation service for a period of one (1) quarter, NAME OF TRANSFEREE
shall forfeit the vehicle within thirty days and the vehicle shall be returned to Yakima
Transit.
3. Yakima Transit is selling NAME OF TRANSFEREE the aforementioned vehicle for
the amount of $500.00 AS IS, WHERE IS, and WITH ALL FAULTS and WITHOUT
RECOURSE regarding the condition of the aforementioned vehicle. Yakima Transit
makes NO EXPRESSED or IMPLIED WARRANTIES of MERCHANTABILITY; NO
EXPRESS or IMPLIED WARRANTIES of FITNESS; and no EXPRESS or IMPLIED
WARRANTIES or GUARANTEES of any other kind regarding the aforementioned
vehicle.
4. The parties to this Agreement agree that Yakima Transit shall have no liabilities of any
sort arising from or related to the vehicle or vehicles covered by this Agreement.
NAME OF TRANSFEREE and any successor shall defend, indemnify and hold
harmless the City of Yakima, Yakima Transit, their officers, agents and employees
from any claims or suits at law or equity, costs and/or demands of any sort, including
reasonable attorneys' fees, arising out of or related to this Agreement, the vehicle or
vehicles covered by this Agreement, or any use by any person of such vehicles.
2004 Vehicle Transfer Packet
5. If NAME OF TRANSFEREE sells, donates or transfers any vehicle or vehicles covered
by this Agreement, NAME OF TRANSFEREE shall require the subsequent transferee
to execute a binding agreement to defend, indemnify and hold the City of Yakima,
Yakima Transit and its officers, agents and employees harmless as set out in the
preceding paragraph.
6. NAME OF TRANSFEREE shall be responsible for all licensing, permits and insurance
of the aforementioned vehicle. Proof of insurance acceptable to Yakima Transit shall
be provided to Yakima Transit as an express condition of delivery of the
aforementioned vehicle to NAME OF TRANSFEREE NAME OF TRANSFEREE
shall promptly carry out all steps necessary to transfer vehicle title to it from the City of
Yakima and/or Yakima Transit.
7. NAME OF TRANSFEREE shall provide to Yakima Transit a report at the end of one
(1) calendar year, containing vehicle odometer readings, number of passengers carried,
and description of use of vehicle. Information shall be submitted to Karen Allen,
Yakima Transit, 2301 Fruitvale Blvd, Yakima, WA 98902 or faxed to 509-576-6414.
8. NAME OF TRANSFEREE will assure they provide transportation services only to
their clients, members, guests or other similar users, not the general public or
individuals in no way affiliated with their group, with vans supplied by this program.
NAME OF TRANSFEREE will not use the vehicle for assisting a campaign for
election or for the promotion of or opposition to any ballot proposition.
9. NAME OF TRANSFEREE represents and warrants that it does not discriminate on the
basis of race, color, creed, sex, disability, age or national origin and that the vehicles
transferred herein will not be used for any illegal, improper or immoral purpose. The
use of the vehicle for any illegal, improper or immoral purpose shall result in forfeiture
of the vehicle within thirty days and NAME OF TRANSFEREE shall return the vehicle
to Yakima Transit.
10. NAME OF TRANSFEREE specifically authorizes and consents to Yakima Transit's
use of any remedy provided by law, including the right of replevin pursuant to RCW
7.64 et seq., to reclaim the subject vehicle in the event NAME OF TRANSFEREE
breaches this Agreement.
11. This Agreement shall be governed by and construed in accordance with the laws of the
State of Washington. The venue for any action to enforce or interpret this Agreement
shall lie in the Superior Court of Washington for Yakima County.
12. The person executing this Agreement on behalf of NAME OF TRANSFEREE
represents and warrants that he/she has been fully authorized by NAME OF
TRANSFEREE to execute this Agreement on its behalf and to legally bind NAME OF
TRANSFEREE to all the terms and obligations of this Agreement.
2004 Vehicle Transfer Packet
DATED:
Ion
City of Yakima, Transit Division
By: `1/-'
Title:
etkijo)
ATTEST:
Transferee
ATTEST:
City of Yakima
By: C�
City Manager
ATTEST:
City Clerk
CITY CONTRAC f NO: /9(97/9 97
RESOLUTION NO: A46(e 01
2004 Vehicle Transfer Packet
AGREEMENT RELATING TO THE EXCHANGE
OF VEHICLE FOR TRANSIT RELATED SERVICES
THIS AGREEMENT between the City of Yakima, Transit Division (commonly known
as and hereinafter called "Yakima Transit"), and
71) e. er cAr (,/'Li(.i,P , hereinafter referred to as the "NAME OF
TRANSFEREE") as follows:
In consideration of the mutual promises of the parties, it is hereby agreed as follows:
1. Yakima Transit shall provide to the NAME OF TRANSFEREE the following described
vehicle:
Make: o cci
Year: i ci 9 C)
Model: Vow- cDo \
VIN: :a S i Nf L i-t-kLo jci 210
2. NAME OF TRANSFEREE shall provide the following services in consideration for the
aforementioned vehicle: To provide enhanced transportation services for residents who
live within the City of Yakima or the immediate surrounding area as described in Sec.2,
description of proposed vehicles use, in the application. Use of the vehicle for other
purposes is prohibited. If NAME OF TRANSFEREE does not use the vehicle for the
above transportation service for a period of one (1) quarter, NAME OF TRANSFEREE
shall forfeit the vehicle within thirty days and the vehicle shall be returned to Yakima
Transit.
3. Yakima Transit is selling NAME OF TRANSFEREE the aforementioned vehicle for
the amount of $500.00 AS IS, WHERE IS, and WITH ALL FAULTS and WITHOUT
RECOURSE regarding the condition of the aforementioned vehicle. Yakima Transit
makes NO EXPRESSED or IMPLII-ID WARRANTIES of MERCHANTABILITY; NO
EXPRESS or IMPLIED WARRANTIES of FITNESS; and no EXPRESS or IMPLIED
WARRANTIES or GUARANTEES of any other kind regarding the aforementioned
vehicle.
4. The parties to this Agreement agree that Yakima Transit shall have no liabilities of any
sort arising from or related to the vehicle or vehicles covered by this Agreement.
NAME OF TRANSFEREE and any successor shall defend, indemnify and hold
harmless the City of Yakima, Yakima Transit, their officers, agents and employees
from any claims or suits at law or equity, costs and/or demands of any sort, including
reasonable attorneys' fees, arising out of or related to this Agreement, the vehicle or
vehicles covered by this Agreement, or any use by any person of such vehicles.
2004 Vehicle Transfer Packet
5. If NAME OF TRANSFEREE sells, donates or transfers any vehicle or vehicles covered
by this Agreement, NAME OF TRANSFEREE shall require the subsequent transferee
to execute a binding agreement to defend, indemnify and hold the City of Yakima,
Yakima Transit and its officers, agents and employees harmless as set out in the
preceding paragraph.
6. NAME OF TRANSFEREE shall be responsible for all licensing, permits and insurance
of the aforementioned vehicle. Proof of insurance acceptable to Yakima Transit shall
be provided to Yakima Transit as an express condition of delivery of the
aforementioned vehicle to NAME OF TRANSFEREE. NAME OF TRANSFEREE
shall promptly carry out all steps necessary to transfer vehicle title to it from the City of
Yakima and/or Yakima Transit.
7. NAME OF TRANSFEREE shall provide to Yakima Transit a report at the end of one
(1) calendar year, containing vehicle odometer readings, number of passengers carried,
and description of use of vehicle. Information shall be submitted to Karen Allen,
Yakima Transit, 2301 Fruitvale Blvd, Yakima, WA 98902 or faxed to 509-576-6414.
8. NAME OF TRANSFEREE will assure they provide transportation services only to
their clients, members, guests or other similar users, not the general public or
individuals in no way affiliated with their group, with vans supplied by this program.
NAME OF TRANSFEREE will not use the vehicle for assisting a campaign for
election or for the promotion of or opposition to any ballot proposition.
9. NAME OF TRANSFEREE represents and warrants that it does not discriminate on the
basis of race, color, creed, sex, disability, age or national origin and that the vehicles
transferred herein will not be used for any illegal, improper or immoral purpose. The
use of the vehicle for any illegal, improper or immoral purpose shall result in forfeiture
of the vehicle within thirty days and NAME OF TRANSFEREE shall return the vehicle
to Yakima Transit.
10. NAME OF TRANSFEREE specifically authorizes and consents to Yakima Transit's
use of any remedy provided by law, including the right of replevin pursuant to RCW
7.64 et seq., to reclaim the subject vehicle in the event NAME OF TRANSFEREE
breaches this Agreement.
11. This Agreement shall be governed by and construed in accordance with the laws of the
State of Washington. The venue for any action to enforce or interpret this Agreement
shall lie in the Superior Court of Washington for Yakima County.
12. The person executing this Agreement on behalf of NAME OF TRANSFEREE
represents and warrants that he/she has been fully authorized by NAME OF
TRANSFEREE to execute this Agreement on its behalf and to legally bind NAME OF
TRANSFEREE to all the terms and obligations of this Agreement.
2004 Vehicle Transfer Packet
DATED: 12I Zk I�
City of Yakima, Transit Division
By: %p7a /Lt ikt_.
Title: L-- - .1,LckY-L
24' —
ATTEST:
Transferee
By:
Title: r��
Witness
ATTEST:
City of Yakima
By:
City anager
ATTEST:
City Clerk
CITY CONTRAC f NO.
RESOLUTION NO
2004 Vehicle Transfer Packet
Date:
To:
PURCHASING' DIVISION
129 North Second Street
Yakima, Washington 98901
Phone (509) 575-6093 — Fax (509) 576-6394
Memorandum
January 24, 2006
Debbie Romias, Financial Services Specialist
Finance Department
From: Maria Mayhue, Buyer
Purchasing Division
Subject: Deposit of Checks for Transit
Please deposit the four attached checks to Transit Vanpool Account
No. 364 -364 -699 -0000 -39510 -FIA.
Check No. 6284 Templo Bautista de Yakima $500.00
Check No. 060563 Provident Services $500.00
Check No. 39260 Stone Church $500.00
Check No. 014626 OIC of WA $500.00
(Southeast Yakima Community Center)
Thank you!
Vehicle Report of Sale
Page 1 of 1
Your transaction of reporting this vehicle as sold has been comp
Please print this form for your records.
STATE OF WASHINGTON - DEPARTMENT OF LICENSING
Vehicle Report of Sale
IPLATE
35254D
I VEHICLE IDENTIFICATION NUMBER
f 1 FB JS31 M21 HA61927
I MODEL YR.
1990
MAKE
FORD
I REPORT OF SALE NUMBER
1064240284
NAME OF SELLER/TRANSFEROR
CITY OF YAKIMA
NAME OF PURCHASER/TRANSFEREE
S.E. YAKIMA COMMUNITY CENTER
ADDRESS OF SELLER/TRANSFEROR
129 NORTH 2ND STREET
ADDRESS OF PURCHASER/TRANSFEREE
1211 SOUTH 7TH STREET
CITY STATE ZIP CODE
YAKIMA WA00 989 1
CITY STATE ZIP CODE
i YAKIMA WA 98901
DATE VEHICLE SOLD
01/23/2006 1p
TODAY'S DATE
01/24/20060 I
SALE PRICE
$500.00
PURCHASER'S DRIVER LICENSE NUMBER
Washington law makes it clear that it is a felony to knowingly make a false statement of fact. (RCW 46.12.210)
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required when there is a change in ownership. This includes, but is not limited to, adding or deleting registered
owner(s), when the vehicle is sold, traded or given as a gift. The transferee/buyer of a vehicle is required to transfer the certificate of
ownership within 15 calendar days, from date of delivery. This can be done using the Application for Certificate of Ownership, TD -420-
001, which may be obtained online or from your nearest Vehicle/Vessel Licensing Office Failure to transfer ownership may result in
monetary penalty (RCW 46.12.101)
IMPORTANT - PLEASE READ:
A seller's report does not transfer ownership.
RCW 46.12.101 and 46.55 require that the registered owner of a vehicle notify the Department of Licensing in writing, on the
appropriate form, of the sale or transfer of the vehicle.
A registered owner selling or transferring interest in a vehicle SHALL BE RELIEVED OF PERSONAL LIABILITY FOR
ABANDONED/JUNK VEHICLE TOWING AND STORAGE CHARGES, and shall not be deemed to be the owner of the vehicle SO AS
TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILITY for the operation of the vehicle thereafter by another person WHEN:
1 He/she has made PROPER ENDORSEMENT AND DELIVERY of the Certificates of Ownership and Registration to the
purchaser/transferee
2. He/she has DELIVERED TO THE DEPARTMENT WITHIN FIVE DAYS from the date of delivery, (excluding Saturdays,
Sundays, State and Federal holidays) a "Report of Sale," indicating THE DATE OF DELIVERY, THE NAME AND ADDRESS
OF THE NEW OWNER or transferee, and A DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the
vehicle persuant to the sale or transfer
IMPORTANT If a Report of Sale has not been submitted to the Department and the new owner has not applied for Certificate of
Ownership and the vehicle is later abandoned, the registered owner will be presumed to have abandoned the vehicle (RCW 46.63 140)
The seller report of sale document relieves the previous owner of civil and criminal liability only if it is completed in its entirety and
delivered to the de •artment within five da s of the sale of the vehicle. RCW 46.12.102
NOTE: The vehicle record will be updated immediately after the data is transferred to our Headquarters Database
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
SELLERS REPORT OF SALE - 1/24/2006 11'33:06 AM
https .//fortress.wa. gov/dol/rosprod/FinalReceiptPrint. asp?P=%14%5DV%5B%2A%5 C%2 1/24/2006
Z.' I H. G ,..JI- VV,.., 111,,
ti..QUREE.,) W1ENEV& cERsh;crAGES - fiNCUJOU'i,liG DE,A.Li7-P -r•i''-i-ir:zcz.
PLEASE PRINT OR TYPE - SEE IMPORTANT INSTRUCTIONS BELOW
LACENSE NUM0SER ,/Ei-:CLE tDENTIMCADON NUMF3ER (VtN) MODEL YEAR MA ''S ESESES,;:,0",' '7,-Pi"PCEET Himr-7','
I
35254D 1FBJS31M2LHA61927 1990 FORD VANPOOL 0224848003
1TRANSFEROR/SELLER: To be I eieesed lirom oivil/urirninal liability for the i
operation of the vehicle you (IlliSi. 11;1 in ihis forrn COM.P“ETEL',.° The vii:3P,.T Ti -VE. 7'01, 1
;office. ngIon veh
wa
competed forrn MUST be :n .----rrom the Jate 0, S(Ek- or .i:e i,:ifi!ii,icio ,s, sei.ivft;e„ii. coo vicoriiiii,tiva.govidol i lilt I 1 I II I I I I i II II
I deliveredlto your oc
lhi E,hiicie license Viir-SSFIE AT: I ,
ra,
Ft4SLLER/TRANSFEROR (CURRENT REGIS r 'RED OWNER)
• (
2P.Or #.:i,. NAME OF PURCHASER/1. AN- SFEREE
ANtza, T.4 COMPLETE ADDRESS OF PURCHASER/TRANSFEREE • C.9111 -
t,___ 12-1V S -ri-• ,
-Pc&A- cil?c6ibi
ale
("(.:Ea NA
COMPLETE
tlif4
CITY
DAT P VJEH WAS SOLD TOD Y'S DATE
11-J?
CIE Nif
V3tLE jPURCHASE PR!CEi SELLER'S ANSFEROR'S SIGNATURE
.IDOU n
.1;711: CITY
Seller Please DETACH HERE
Seller Please DETACH HERE
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required vi,d-te.i.1 Lhere is a change in ownership This includes. but is not limited to, adding or deleting registered
owner(s), when the vehicie is sold, trotted or given as a gift. The transfereeibuyei of a vehicle is cei..;uired to transfer the sfehicie certificate
of ownefship within 15 calendar days, from date Or delivery This can be dune using the Application for Certificate of Ownership, 70 -420-
001, which may be obtained from the DOL Website at. wwwwei gov/dol or from your nearest Vehicie 'jeans:rig Office Failure to tfanufer
ownership may resultin monetary penafty pursuant to PisC\Af 46.12.101(6).
_ -----------_ _____________
,nf '55', ''',''' e, f.;"
1 A S , , -, .-
. ,7,%..,,i
25 'Detach this poi i kin eitti ,T 2r._ "3",-V CC /0re, es (IMPORTANT A seller's report does not transfer ownership )
iver t ) ;IOU' icr.ai steniLe ice, is 1. C, agen1. A 'TF:i ,iic a. fee i0 ap,pF;
caHetc,d 'irom, -7,...,43.: o,3 'F.tLtii'', ee L, i --e Ho. -isic:-,i,'ir,i,;(t3 0.-' s, i...,, ,.e.-,..., ,,
State and Feder a' riiooays)
5) G le dr:a top porion cre[ease Oectifipai.e 01 O ,fla"..., -':;)) 1.,0 ft' /th puye„ w'io mt.si La{e il It-, p 4.3,,ia a i'eensii;
transfer ownership
RiCliii4-5.,2.1C1 and 46.55 requii.fE :3 113& registe.red -Avrar cf a vehicYe :t?y j'tF.: Oep7r.e:r :i: ficer a:ST,7
Org ti;e aprx-apr(are. ,i'c-iil,t3f ,YTC.-; 55rr,2 a. riraisf,et- or n'%s.- vehie.--le, L'i, re0s;erect owncr sel;r,g 0. tranPfeiTirig i(iei-esi in 0ireltlit)3.,
BE RF=LIEVED Cr PERSON; LiAr-3 -1-',,' FOR ABANDONED/jUNK VEHiCiF TOihri.io AiisiE- STORAGE
sha not be deemed to be the, c\i'vner of the vehicle SO AS TO BE SUBjECT TO CM_ OR CRIMNAL Liki311...iTY ifPr t'P
_. ..
I
operation of the vehicle thereafter by another person WHEN- 1) He/she has made PROPER ENDORSEMENT AND i3E-Lro'ERY
of the Certificates of Ownership and Registration to the purchaser/transferee 2) He/she has DELNERED TO THE DEPARTMENT
WITHIN ENE DAYS from the date of delivery, (excluding Saturdays, Sundays, State and Federal holidays) a "BeHer's eport
of Sale," indicating THE DATE OF SALE, THE NAME AND ADDRESS OF THE NEW OWNER or transferee, and A
DESCRiPTiON of the 'vehicle, OF PROPER DOCUMENTS for registration of the vehicle pursuant to the sale or transfer
--,--------...-----...--------.-------;
iViPORTAN_ : if e Seller's Report 0f Sale has not been submitted to the department and the new owner has not
applied for Ce,rtificate 01 Ownership and the Vehicle is later abandoned, the reaistered owner wdl
be presumed to have abandoned the vehicle (RCV\i' 46 63 '140)
06/01 The Department of Licensing has a policy of provithng equal access to i0 services. If you need spethal accomrnodatitht, please call /260)902-3600 or TT"! /360)664-8885
PROGRESSIVE INSURANCE COMPANIES
RECEIPT
CODAY'S DATE: 01/23/06 09:55AM
GENCY: PEREZ INSURANCE AGENCY, INC
8 E WASHINGTON AVE 102
YAKIMA, WA 98903
NSURED'S NAME: JAMES C PARKS
)BA: SOUTHEAST COMMUNI
'his acknowledges receipt of $
'ither by direct payment to Pr
_gent accepting on behalf of
l
CENTE
076.00
essive
-ssiv
his payment is made with Check #014996
,oiicy number 03369100-0.
'his is an Express Money transfer.
Progressive Insurance Companies
r by payment to the independent
Insurance Companies.
for downpayment on
Insured Copy
PROGRESSIVE ADVANTAGE
1ODAY'S DATE: 01/23/06
TAME: JAMES C PARKS
)BA: SOUTHEAST COMMUNITY CENTE
'AYMENT OPTION: 1 -PAY
PAYMENT SCHEDULE
POLI1CY #: 03369100-0
EFFECTIVE DATE: 01/23/06
TOTAL PREMIUM: 1076.00
DUE DATE AMOUNT
01/23/06 1076.00
)1/23/06 RR:10/05 WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
*******************x nx********************************************************
PAGE 1
JPLOAD MESSAGE: Upload Successful on 01/23/2006 12:55PM
\ref. . 6010
'OMPANY INFORMATION:
JNITED FINANCIAL CASUALTY CO. P.O. Box 94739 Cleveland OH 44101
GENT INFORMATION: TOTAL PREMIUM: 1076.00 POLICY #: 03369100-0
'EREZ INSURANCE AGENCY, IN DOWN PAYMENT: 1076.00 LEVEL: ADVANTAGE
E WASHINGTON AVF 102 BALANCE DUE: 0.00
-AKIMA, WA 98903
509)457-4662 MI -12908
'EREZ, STEPHANIE
DOWNPAY REO_: 1076.00
PAY PLAN: 1 -PAY
DOWNPAY METH: EXPRESS MONEY
(Do Not Retain Commission)
POLICY TERM: ANNUAL
NAMED INSURED / BUSINESS
EFF DATE: 01/23/06
EFF TIME: 09:52AM
USINESS TYPE: PASSENGER TRANSPORTATION (NOT FOR HIRE)
UB BSNS TYPE: OTHER PASSENGER TRANSPORTATION (NOT FOR HIRE)
THER: COMMUNITY CENTER PICKING UP KIDS FOR PROGRAMS
. Are any of the listed vehicles rented or leased to others? NO
. Are at least half of the vehicles listed on this policy used in the
usiness? YES
. Are any listed vehicles used to transport passengers For -Hire? NO
PPLICANT: Individual/Sole Prop.(I), Partnership (P), or Corp (C)? I
MPLOYER IDENTIFICATION NUMBER:
AME: JAMES C PARKS
BA: SOUTHEAST COMMUNITY CENTE
DDR: 1211 S 7TH ST
YAKIMA , WA 98901-
NSURED'S PHONE: (509)575-6114
NSURED'S E-MAIL:
ONE
)RDER FINANCIAL RESP: YES
NAME
JAMES PARKS
HOME STREET ADDRESS
1211 S 7TH ST
FINANCIAL RESPONSIBILITY
SUFFIX BIRTH DATE AGE
NONE 10/20/49 56
CITY STATE
YAKIMA WASHINGTON
SOCIAL SECURITY #
253-82-3437
ZIP
98901-
r*********************** **** ******** ************ ********** ********** * ***
)1/23/06 RR:10/05 WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
*************************4-*****************************************************
PAGE 2
TEH
YR MAKE
1990 FORD
TEH
VEHICLE INFORMATION
VEHICLE ID
MODEL NUMBER
CLUB WAGON SUPR 1FBJS31M2LHA61927
TRAILER PERSONAL
HITCH USE
�3
GARAGING
ZIP TERR
98901 08
CUR VEH
VALUE
10000
1
PAE
VALUE
0 v
VEHICLE QUESTIONS
•
BODY USE
TYPE CLASS
06 L
TOTAL
STATED
AMT RADIUS
10000 100
DR
NO
1
'EH 1
1. Is this vehicle used for business, personal or both? BUSINESS ONLY
DRIVER INFORMATION - LIST ALL DRIVERS
(Failure to accurately and completely report all driver information may
result in premium differences and service delays.)
)R# DRIVER'S NAME
JAMES PARKS
)R# LICENSE NUMBER
PARKSJC51.6P0
ST
WA
BIRTH MARITAL
DATE AGE STATUS
10/20/49 56 MARRIED
SOCIAL EXCLUDED
SECURITY # DRVR Y/N
N
PROOF OF PRIOR QUESTIONS
PTS
0
SR22
Y/N CASE #
N
CDL CDL ORIG
Y/N YR ISSUE
N
s Applicant currently insured? NO
'hich Company is your current policy with?
That is your current policy number?
affective Date of Current Insurance Coverage:
,xpiration Date of Current Insurance Coverage:
!hat is the liability limit closest to the insured's current policy:
as Applicant had continuous coverage for at least one year?
UNDERWRITING QUESTIONS
c**************** ******w************** * * **
)1/23/06 RR:10/05 WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
<***********************;;******************************************************
)oes Applicant require Any Waivers of Subrogation? No How Many? 0
(Attach list of names & addresses)
dumber of Additional Insureds Required 0
PAGE 3
'ILINGS:
)o we insure all commercial vehicles the insured owns? NO
)o you have private passenger type autos insured under another policy? NO
)o we insure all vehicles that the insured uses in their business? NO
ADDITIONAL POLICY QUESTIONS
'ear the business was established?
ear the Principal Operator sparled in current industry / occupation?1 n8n
7VV
oes the insured currently have General Liability Insurance or a Business
wners Policy? GENERAL LIABILITY INSURANCE
1980
4************************* ** *** • **.* * **********
)1/23/06 RR:10/05 WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
***********************x******************************************************
COVERAGES
PAGE 4
[ODEL YR 1990
.SE/BODY L/06
I -PD 50/100/25
IM 50/100
TMPD 25 W/100
[ED -PAY NONE
IP 35,000
R-THFT N/A
LIMP 1(1(1
'OLL 250
,N -HOOK NONE
ON -TRK NONE
Ll fr/V1a_LA_La1/1-1y.
ubTotal 1076.00
dd'l Coverages
ON -OWNED NONE 0
IRED-AUTO NONE 0
KLL1 NONE 0
KLL2 NONE 0
KLL3 NONE 0
RLR -INT NONE 0
ubTotal 0.00
otal Fees: 0.00
otal Premium - 1076.00
OVERAGE DESCRIPTION
RLR -INT NONE
Policy Discount(s): Paid -In -Full
DISCOUNTS
VEH
1
520
54
15
0
276
0
FR
1 43
0
0
1076
1 L 15 6
)1/23/06 RR:10/05 WASHINGTON
JAMES C PARKS
ADVANTAGE
POLICY #: 03369100-0
PAGE 5
***********************�;******************************************************
<*****************************************************************************
REPORT ALL ACCIDENTS IMMEDIATELY
24 HOURS A DAY, 7 DAYS A WEEK
1-800-274-4499
'all us immediately so we can go to work for you.
NSTRUCTIONS TO INSURED IN CASE OF ACCIDENT OR LOSS:
Obtain full names, addresses, phone numbers, and license numbers of all
persons involved and all witnesses.
Do not admit liabi'ity or discuss the accident with anyone except police
or company represe-0,7ative.
Call Progressive i,,m,ediately.
OTE: FOR QUESTIONS REGARDING YOUR POLICY OR BILL, PLEASE CALL: 1-877-776-2436
***********************KAk*****************************************************
NOTES SECTION
OTHER PASSENGER TRANSPORTATION (NOT FOR HIRE) PASSENGER TRANSPORTATIO
COMMUNITY CENTER PICKING UP KIDS FOR PROGRAMS
EE3.;7'£a�•' .F �'S }''tr�"r+`•'4"iTM„3'
<*******,*********************************************** * *********** * ****
PAGE 6
)1/23/06 RR:10/05 6•WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
<**********************xxYx*****************************************************
INSURED'S SIGNATURE
'he insured hereby applies to Company for a policy of insurance as set forth in
his application on the basis of statements contained herein. The insured
_grees that such policy shall be null and void if such information is false, or
lisleading, or would materially affect acceptance of the risk by the Company.
'he insured understands that this application becomes part of the insurance
>olicy. The insured agrees to submit to loss control inspections as often as
he Company may reacnnahi;' regiiire. The in.s re agrees that rafiical to submit✓
o an inspection is grounds for cancellation of this policy. The insured
grees that no coverage wi_I.1 be bound and this policy shall be void from
nception if the payment is not honored by the bank. The insured understands
hat a service charge of 515.00 will be assessed if any check offered in
,ayment is returned from the bank unpaid.
he insured agrees to pay the installment fees shown on the billing statement
hat become due during the policy term and each renewal policy term in
ccordance with the payment plan the insured selects. The insured understands
hat the amount of these fees may change upon policy renewal or if the insured
hanges the payment plan. The insured also understands that the amount of
hese fees may change if the premium is increased due to inaccurate or
ncomplete information in this application.
he insured agrees to pay a late fee of $5.00 during the policy term and each
enewal policy term when either the minimum amount due is not paid or payment
s postmarked more than 05 days after the premium due date. The amount of this
PP may 'hinge iipnn policy renewal.
he insured acknowledges that the Company and its affiliates may collect
nformation from consumer reporting agencies, such as driving record and credit
istory reports. The Company may use an insurance credit score based on the
nformation contained in that credit history report. This information will be
sed to underwrite the insurance and provide an accurate quote in an appropriate
Lnderwriting company. Future reports may be used to update or renew the
nsurance. The insured authorizes the .Company and its affiliates to obtain
uture reports to update or renew the insurance or to offer replacement
nsurance. The insured has or will obtain from existing and new drivers
mployed or contracted by the insured, an acknowledgement that their driving
ecord information may be disclosed to the insured or their employer,
•ontractor, or agent in connection with the insurance being applied for
Lereunder.
nature of Insured
Date:
.69
,
. {a" 'si- `,1i 60,1' ..'4:'44 .fie ��'-i`.,�ri'_k- ki+. y"i �`:a` f� z"^�; '` {fi. ::.kea'' . h; ,§.' .'.`' t` `"K3i?`'f �.z,..:. »......_,
********** * ********************* ************* ** * ******************** ****
1/23/06 RR:10/05 WASHINGTON ADVANTAGE
JAMES C PARKS POLICY #: 03369100-0
***********************�Yrk****************************************************
AGENT SIGNATURE
he undersigned hereby warrants and certifies that all information contained
erein is correct to the best of his/her knowledge, that his form was
ompleted and then signed by the insured, that a complete copy hereof has
een given to the insured, and that a duplicate signed copy hereof has been
etained.
PAGE 7
Si
re .f Producing A
Date: / 02?
gent Compensation Disclosure
-e insurance producer that sold you this policy is a licensed independent
-surance agent authorized by UNITED FINANCIAL CASUALTY CO. and by other
-surance companies to solicit business on their behalf. We believe that
-dependent agents who represent more than one company can better assist you in
finding the combination nr coverage, price and service that meets your needs.
will pay your agent a commission for placing your policy with us. We may
lso help your agent pay for advertising and marketing that is designed to
ttract new customers.
iur agent may also be eligible for additional compensation, based upon the
glume and profitability of certain business he or she places with us.
Vehicle Report of Sale
PLATE
35255D
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
STATE OF WASHINGTON - DEPARTMENT OF LICENSING
Vehicle Report of Sale
VEHICLE IDENTIFICATION NUMBER I MODEL YR. MAKE
1 FBJS31 MOLHA61926 . 1990 FORD
Page 1 of 1
IREPORT OF SALE NUMBER
n6-4030512
NAME OF SELLER/TRANSFEROR
CITY OF YAKIMA
NAME OF PURCHASER/TRANSFEREE
PROVIDENT HORIZON GROUP
ADDRESS OF SELLER/TRANSFEROR
129 NORTH 2ND STREET
ADDRESS OF PURCHASER/TRANSFEREE
PO BOX 9727
CITY
I YAKIMA
]� v�sl�iiaT
1 DATE \/FI-II(CI E Sr)!n
I 12/21/2005
STATE ZIP CODE
ArA
vi -i
Henna
TODAY'S DATE I -SA E PRICE
101/03/2006 I $500.00
CITY
YAKIMA
I
STATE
i _PI CHASER'S r1I-Ri. LICENSE NUM
VIA
ZIP CODE
94909
Washington law makes it clear that it is a felony to knowingly make a false statement of fact. (RCW 46.12.210)
i
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required when there is a change in ownership This includes, but is not limited to, adding or deleting registered
owner(s), when the vehicle is sold, traded or given as a gift. The transferee/buyer of a vehicle is required to transfer the certificate of
ownership within 15 calendar days, from date of delivery This can be done using the Application for Certificate of Ownership, TD -420-
001, which may be obtained online or from your nearest VehicleNessel Licensing Office Failure to transfer ownership may result in
monetary penalty (RCW 46 12.101)
IMPORTANT - PLEASE READ:
RCW 46.12.101 and 46.55 require that the registered owner of a vehicle notify the Department of Licensing in writing, on the
appropriate form, of the sale or transfer of the vehicle.
A registered owner selling or transferring interest in a vehicle SHALL BE RELIEVED OF PERSONAL LIABILITY FOR
ABANDONED/JUNK VEHICLE TOWING AND STORAGE CHARGES, and shall not be deemed to be the owner of the vehicle SO AS
TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILITY for the operation of the vehicle thereafter by another person WHEN
1 He/she has made PROPER ENDORSEMENT AND DELIVERY of the Certificates of Ownership and Registration to the
purchaser/transferee
2. He/she has DELIVERED TO THE DEPARTMENT WITHIN FIVE DAYS from the date of delivery, (excluding Saturdays,
Sundays, State and Federal holidays) a "Report of Sale," indicating THE DATE OF DELIVERY, THE NAME AND ADDRESS
OF THE NEW OWNER or transferee, and A DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the
vehicle persuant to the sale or transfer
IMPORTANT If a Report of Sale has not been submitted to the Department and the new owner has not applied for Certificate of
Ownership and the vehicle is later abandoned, the registered owner will be presumed to have abandoned the vehicle. (RCW 46 63 140)
The seller report of sale document relieves the previous owner of civil and criminal liability only if it is completed in its entirety and
delivered to the de.artment within five da s of the sale of the vehicle. RCW 46.12.102
NOTE. The vehicle record will be updated immediately after the data is transferred to our Headquarters Database
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
SELLERS REPORT OF SALE - 1/3/2006 2:06:39 PM
https //fortress.wa.gov/dol/rosprod/FinalReceiptPrint.asp?P=%14%5D%2A%2C%5B%5EV 1/3/2006
'RED 'WHENEVER OWNEP.SHP CHANGE'S NCLUFTY" JrLES, TR!/(.1.-.(il7-(i'll • c(e'... R -5E r)N! Y
..,47=7,7=7,1a):77WITIME7,7"77,777,t6=77.,r,fTr4.'"
L. =4L'' "4".4v4fr.1:1:44-6frit,h'hl:.:-.fiwi2.,;r"-'1.t',64,i0,30le.A• ' ,iff,i4t? :,,,,,P.i Mr-,
PLEASE PRINT OR TYPE - SEE IMPORTANT INSTRUCTIONS BELOW
LICENSE F,IUDBDER ,rEE.)1,-,Lri IIDENTISK,A,TiON NUMBER t'111,1) MOinL. YES,A, MAKE SER:ESLOD' rl:S.,11,;OATE NIUAtiSER -1
35255D 1FBJS31MOLHA61926 1990 FORD VANPOOL 0224848004
TRANSFEROTTSELLER. To be released from civVeriminal }lability for the
operation of the vehicie you must fill in this form COMPLETELY The
compiel.ed form musT be delivered to your local washington vehicle license
office, within 5 days from be date of sale of the vehicie. A service fee
wiS apwy
NAV F ELLER/TRANSFER.OR (CURREVITEGIS;ERED OVVNER) ''WNAME OF PLIRCHASERITRANSEEP,EF
tiq
COMP
VST THE DOL.
WEBSFIE AT
www wa.govildo
11
1
.1111
CA
•q`.P C0N,IPLEIE ADDRESS OF PURCHASE. ,ITRANSFEREE
I 1-0Sfejlt: C-i_ccur
ZIP CODE^
7 STATE
I 6 t •
DATEWASS0LD 1 TOD Y, DATE V_LICLE PURCHASE PRICE SELLER'S T AkISFERORS SIGNATURE
0 S 2I OS 4504()_
(CLAILC:c -71 i•S
-
_ _ _ij0tr
_
Seller Please DETACH HERE Seller Please DETACH HERE
ZIP CODE
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required when Here is a change in ownership This includes, hu i is no limited to, adding ot deleting registered
owner(s) wen the vehicle, is sold, traded LY/I given as a gift. Theiiransfereelbuyc.-tr of a ‘,ehinie is -egiiired fo transfer the vehicle certfficai;-_,
of ownership \ivithin 15 calendar days cm date of delivery This can hs 4ore using the 6..pplication for erttiipate iThivnership, TD -a20_
001 which niiiPy be obtained ft0ITI the DOL V`Jebsite at: www wa goiti/dol or from your nearest Licensing Office Failure to transfer
ownership_ rnav result in monetarypenaftv pursuant to ROW 41,6.1 2.1 01 (.8).
t'ie z - r" e
!TE--. E t7.; 7.I2r)4CC
etach this 11 onion d r,Ii(e i'')pi,/ for VOLK records (IMPORTANT A seller's report does not transfer ownership )
DeTh.ier to .(of.., ocavehicle lir nsifig aciirit. A ,ervice tee Wii[ appki
4; The completed 'form —r(3f: he. .2,ceiviad by the ken:ngag, hit -7 ,r,:tnys or1, E
Stati,1 and Federal hclida.ys)
0, Give ,he lop peter, cre!eased certiiicat,„; 0; Ownership y to the buyer, who must it to a "ehicin ii.-ieinsing office tc.
transfer ownership
P0lt1146.12,•Til and 46.55 rect,Ft.ire fht, the regftariad ownein of a ie..hicie ncitify the Et,eparin?,Inii, AijttahS;Plig in writing,
or the. approprTate fOrrn's of .11e, sale or transfer of the. veh!cie. ,A registered owner selling or transferring interest in a vehicle SHA I L
BE RELIEVED OF PERSONAL LABILITY FOR ABANDONED/JUNK VEHICLE TOWING AND STORAGE CHARGES, and
shall not be deemed to be the owner of the vehicle SO AS TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILITY for the
operation of the vehicle thereafter by another person \A/HEN. 1) He/she has made PROPER ENDORSEMENT AND DELIVERY
of the Certificates of Ownership and Registration to the purchaser/transferee 2) He/she has DELIVERED TO THE DEPARTMENT
WITHIN FiVE DAYS from the date of delivery, (excluding Saturdays, Sundays, State and Federal holida'y's) a "Seller's Report
of Sale," indicating THE DATE OF SALE, THE NAME AND ADDRESS OF THE NEW OWNER or transferee, and A
DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the vehicle pursuant to the sale or transfer
!RFRORTANT: if a Selle7s Report ef Sale has not been submitted to the departme7ar lid the new owner has not
applied for Certificate of Ownership and the vehicle is later abandoned, the registered owner will
be presumed to_have..abandoned the vehicle (RCV\./ 46 63 143) _
06/01 The Department of Licensing has a policy of providing equal access to 45 services. If you need special accommodation, please call (360) 902-3600 or TTY (360) 664-8865.
❑Renewal of No.
Policy No. 02CA37837090000
ITEM ONE
AIG
AMERICAN INTERNATIONAL COMPANIES°
70 Pine Street, New York, NY 10270
(212) 770-7000
Coverage is provided by
GRANITE STATE INSURANCE CO.
(a capital stock company)
BUSINESS AUTO DECLARATIONS
Named Insured & Mailing Address
The Provident Horizon Group
440 Barnard Blvd -
P.O. Box 427
Sunnyside, WA 98944
Producer's Name & Mailing Address
IRWIN SIEGEL AGENCY, INC
25 LAKE LOUISE MARIE RD
ROCK HILL, NY 12775
FORM OF BUSINESS:
® CORPORATION ❑ PARTNERSHIP ❑ LIMITED LIABILITY COMPANY ❑ INDIVIDUAL ❑ OTHER
POLICY PERIOD: From 11/01/2005 to 11/01/2006 at 12:01 A.M. Standard Time at your mailing address shown above.
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH
YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
POLICY PREMIUMS:
PREMIUM FOR ENDORSEMENTS $ .00
',ESTIMATED TOTAL PREMIUM $11,140.00
This policy may be subject to final audit.
PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE UNDER TERRORISM RISK INSURANCE ACT 2002:
$111.00
SCHEDULE OF STATE TAXES, FEES AND SURCHARGES, IF APPLICABLE:*
* State Taxes, Fees and Surcharges shown are in addition to the above
referenced Estimated Total Premium.
ENDORSEMENTS ATTACHED TO THIS POLICY:
IL 0017 - Common Policy Conditions (IL 01 46 in Washington)
IL 00 21 - Broad Form Nuclear Exclusion (Not Applicable in New York)
SEE ATTACHED FORMS SCHEDULE Countersigned:
By—-------- - - - - -- -
THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS, IF APPLICABLE, TOGETHER WITH THE COMMON POLICY
CONDITIONS, COVERAGE FORMS, AND FORMS AND ENDORSEMENTS IF ANY ISSUED TO FORM A PART THEREOF COMPLETE THE
ABOVE NUMBERED POLICY
Date Issued: 11/03/2005
46169 (7/03)
CA DS 03 10 01
Includes copyrighted material of Insurance Services Office,lnc., with its permission. ISO Properties, 2000 Page 1 of 4
ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS
This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos"
shown as covered "autos" "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the Covered Autr s
Section of the Business Auto Coverage Form next to the name of the coverage.
COVERAGES
COVERED AUTOS
(Entry of one or more of the
symbols from the Covered Autos
Section of the Business Auto
Coverage form , o'ws which autos
are covered autos.)
LIMIT
THE MOST WE WILL PAY FOR ANY ONE
ACCIDENT OR LOSS
PREMIUM I
LIABILITY
01
$1,000,000 Deductible 5
$8,283.00
PERSONAL INJURY PROTECTION
(or equivalent No-fault Coverage)
2002, DODGE RAM, T, 2B5WB35Z22K1 10779
$ 15,700
ADDED PERSONAL INJURY
PROTECTION (or equivalent added
No-fault Coverage)
2
2002, DODGE RAM, T, 2B5WB35Z22K106923
$ 15,300
PROPERTY PROTECTION
INSURANCE (Michigan only)
WA
3
1999, MITSUBISHI GALANT, P, 4A3AA46G2XE150392
AUTO MEDICAL PAYMENTS
02
$5,000
$379,00
MEDICAL EXPENSE AND INCOME
LOSS BENEFITS
(Virginia only)
$ 12,5004
WA
UNINSURED MOTORISTS
02
Included in UNDERINSURED MOTORIST COVERAGE
INCLUDED
UNDERINSURED MOTORISTS
(When not included in Uninsured
Motorists Coverage)
02
$ 500,000
$1,204.00
PHYSICAL DAMAGE
COMPREHENSIVE COVERAGE
07 08
ACTUAL DEDUCTIBLE STATED - IN ITEM THREE FOR EACH
CASH COVERED AUTO,BUT NO DEDUCTIBLE APPLIES TO LOSS
VALUE OR CAUSED BY FIRE OR LIGHTNING. See ITEM FOUR For Hired
COST OF Or Borrowed "Autos".
5351.00
PHYSICAL DAMAGE
SPECIFIED CAUSES OF LOSS
COVERAGE
Seating
Capacity
REPAIR, DEDUCTIBLE STATED IN ITEM THREE FOR EACH
WHICHEVER COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR
IS LESS, VANDALISM. See ITEM FOUR For Hired Or Borrowed "Autos"
MINUS
PHYSICAL DAMAGE
COLLISION COVERAGE
07 08
DEDUCTIBLE STATED IN ITEM THREE FOR EACH
COVERED AUTO See ITEM FOUR For Hired Or Borrowed
"Autos".
$865.00
PHYSICAL DAMAGE TOWING
AND LABOR
02
$ 50 For Each Disablement Of A Private Passenger "Auto".
62k
3
PRFMII IM FOR ENDORSEMENTS
.00
6481
* ESTIMATED TOTAL PREMIUM
$11,140.00
is policy may be subject to final audit.
ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN
Covered
Auto No.Original
DESCRIPTION
PURCHASED
TERRITORY
Year, Model, Trade Name, Body Type, Serial
Number (s), Vehicle Identification Number (VIN)
Cost
New
Actual
Cost $
NEW (N)
USED (U)
Town $ State Where The
Covered Auto Will Be Principally
Garaged
1
2002, DODGE RAM, T, 2B5WB35Z22K1 10779
$ 15,700
WA
2
2002, DODGE RAM, T, 2B5WB35Z22K106923
$ 15,300
WA
3
1999, MITSUBISHI GALANT, P, 4A3AA46G2XE150392
$ 15,000
WA
4
1992, FORD TAURUS, P, 1 FACP50U5NG248466
$ 12,5004
WA
Covered
Auto No.
CLASSIFICATION./4-
k``
== r` :..,.
Radius
Of
Business
Use
S =service
Size GVW,
GCW Or
Vehicle
Group Age
Primary
Rating
Factor
Secondary
Rating
Code
Except For Tow ng, All Physical Damage Loss is Payable
To You And The Loss Payee Named Below As Interests May
Operation
R =retail
C =commercial merciaaiLiab.
Seating
Capacity
Phy.
Dam.
Factor
Appear At The Time Of The Loss
1
S
6
3
6481
2
S
6
3
6481
3
S
6
7398
4
S
6
7398
46169 (7/03)
CA DS 03 10 01
Includes copyrighted material of Insurance Services Office,Inc., with its permission. ISO Properties, 2000 Page 2 of 4
ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN (CONTINUED)
,vered
Auto No.
1
2
COVERAGES — PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any
.Column below means that the limit or deductible entry in the corresponding ITEM TWO column applies
Instead.
LIABILITY
PERSONAL INJURY
PROTECTION
ADDED P
P.I.P.
PROPERTY PROTECTION
(Michi. an Onl
Limit
$ 1,000,000
$ 1,000,000
Premium
$ 695
$ 695
Limit Stated In
Each P.I.P. End.
Minus Deductible
Shown Below
_------
Premium
Limit Stated In Each
Added P.I.P. End.
Premium
Limit Stated In
P.P.I. End. Minus
Deductible
Shown Below
Premium
.
3
$ 1,000,000
$ 585
4
$ 1,000,000
$ 585-_---
Total,,Ka-;
Premium
tit1sY'n
$ 2,560zy
Covered
Auto No.
COVERAGES
Column below
— PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any
means that the limit or deductible entry in the corresponding ITEM TWO column applies
Instead.
AUTO MEDICAL PAYMENTS
MEDICAL EXPENSE AND INCOME LOSS BENEFITS (Virginia Only)
Limit
Premium
Limit Stated In Each
Medical Expense And
Income Loss Endorsement
For Each Person
Premium
1
$ 5,000
$ 32
2
$ 5,000
$ 32
3
$ 5,000
$ 26
4
$ 5,000
$ 26
Total
Premium
z
M
$ 116w.
�'
Covered
Auto No.
COVERAGES — PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any
Column below means that the limit or deductible entry In the corresponding ITEM TWO column applies
Instead.
COMPREHENSIVE
SPECIFIED CAUSES OF LOSS
COLLISION
TOWING & LABOR
Limit Stated In ITEM
TWO Minus
Deductible Shown
Below
Premium
Limit Stated In ITEM
TWO Minus
Deductible Shown
Below
Premium
Limit Stated In ITEM
TWO Minus
Deductible Shown
Below
Premium
Limit Per
Disablement
Premium
1
$ 1,000
$ 38
$ 0
$ 1,000
$ 82
--_
2
$ 1,000
$ 38
$ 0
$ 1,000
$ 82
—
3
$ 1,000
$ 23
$ 0
$ 1,000
$ 92
$ 50
$ 14
4
$ 1,000
$ 23
$ 0
$ 1,000
$ 92
$ 50
$ 14
Total
Premium
p a
$ 122
#
,
$ 348
g
ua k
$ 28
ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS
LIABILITY COVERAGE — RATING BASIS, COST OF HIRE
STATE
ESTIMATED COST OF HIRE
FOR EACH STATE
RATE PER EACH $100
COST OF HIRE
FACTOR (If Liability
Coverage Is Primary
PREMIUM
WA
IF ANY
$
$ 74.00
TOTAL PREMIUM
$ 74.00
Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family
members). Cost of hire does not include charges for services performed by motor carriers of property or passengers.
46169 (7/03)
CA DS 03 10 01
Includes copyrighted material of Insurance Services Office,Inc., with its permission. ISO Properties, 2000 Page 3 of 4
PHYSICAL DAMAGE COVERAGE
COVERAGES
LIMIT OF INSURANCE THE MOST
WE WILL PAY DEDUCTIBLE
ESTIMATED ANNUAL
COST OF HIRE
RATE PER EACH
S100 ANNUAL
COST OF HIRE
PREMIUM
COMPREHENSIVE
ACTUAL CASH VALUE , COST OF REPAIR OR 550.000,
WHICHEVER IS LESS, MINUS $100 DED FOR EACH
COVERED AUTO O NO DEDUCTIBLE APPLIES TO LOSS
CAUSED BY FIRE OR LIGHTNING.
$
5
$ 24.00
SPECIFIED CAUSESOF
LOSS
ACTUAL CASH VALUE OR COST OF REPAIR, WHICHEVER IS
LESS. MINUS $ DED. FOR EACH COVERED
AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM.
$
$
$
COLLISION
ACTUAL CASH VALUE, COST OF REPAIR 00 $50,000
WHICHEVER IS LESS, MINUS $1,000 DED FOR EACH
COVERED
AUTO.
$
$
$ 1.00
TOTAL PREMIUM
$ 25.00
ITEM FIVE SCHEDULE FOR NON -OWNERSHIP LIABILITY
NAMED INSURED'S BUSINESS
RATING BASIS
NUMBER
PREMIUM
Other Than A Social Service Agency
Number Of Employees
LIABILITY
COVERAGE
$
LIABILITY
COVERAGE
Number Of Partners
$
Social Service AgencyNumber
Of Employees
50
$ 237.00
$
Number Of Volunteers
$
$
TOTAL
$ 237.00
ITEM SIX SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS — LIABILITY COVERAGE — PUBLIC AUTO OR
LEASING RENTAL CONCERNS
ESTIMATED
YEARLY
❑ Gross Receipts
❑ Mileage
RATES
0 Per $100 Of Gross Receipts
0 Per Mile
PREMIUMS
LIABILITY
COVERAGE
AUTO MEDICAL
PAYMENTS
LIABILITY
COVERAGE
AUTO MEDICAL
PAYMENTS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL PREMIUMS
$
$
MINIMUM PREMIUMS
$
$
When used as a premium basis:
FOR PUBLIC AUTOS
Gross Receipts means the total amount to which you are entitled for transporting passengers, mail or merchandise during the policy
period regardless of whether you or any other carrier originate the transportation. Gross Receipts does not include:
A. Amounts you pay to railroads, steamship lines, airlines and other motor carriers operating under their own
Irr or PUC permits.
B. Advertising revenue.
C. Taxes which you collect as a separate item and remit directly to a governmental division.
D. C.O.D. collections for cost of mail or merchandise including collection fees.
Mileage means the total live and dead mileage of all revenue producing units operated during the policy period.
FOR RENTAL OR LEASING CONCERNS
Gross receipts means the total amount to which you are entitled for the leasing or rental of "autos" during the policy period and
includes taxes except those taxes which you collect as a separate item and remit directly to a governmental division. Mileage means
the total of all live and dead mileage developed by all the "autos" you leased or rented to others during the policy period.
In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid
unless countersigned by our authorized representative.
46169 (7/03)
CA DS 03 10 01
President
Secretary
Includes copyrighted material of Insurance Services Office,Inc., with its permission. ISO Properties, 2000 Page 4 of 4
SCHEDULE OF COVERED AUTOS YOU OWN
EXTENSION OF DECLARATIONS
ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN (CON'T)
".ICY NUMBER:
A961
(Ed 7/03)
Covered
Auto No.
DESCRIPTION
PURCHASED
TERRITORY
Year, Model, Trade Name, Body Type, Serial
Number (s), Vehicle Identification Number (VIN)
Original
Cost
New
Actual
Cost
NEW (N)
USED (U)
Town $ State Where The
Covered Auto Will Be Principally
Garaged
5
1979, FORD WAGON, T, E11 GBDE2335
$ 12,500
WA
6
2000, UTILITY, Util Trail, TBA
$ 5,000
WA
7
1991, FORD AEROSTAR, T, 1 FMCALLU8MZB38609
WA
8
1993, GMC VAN, T, 1GTGC33K8PJ725726
$ 15,000
WA
9
1997, FORD CLUB, T, 1FBJS31S8VHA28819
$ 13,500
WA
10
1999, FORD, Lt Trk, 1 FTNW20L9XEA90224
$ 16,500
WA
11
1998, FORD W INDSTAR, T, 2FMZA51 U4WBE51695
$ 15,000
WA
12
2000, SUBARU FORESTER, T, JF15F6351YH720850
$ 23,000
WA
13
2003, FORD ECONLINE, T, 1 FBSS31 L43HB48109
$ 22,500
WA
14
2003, UTILITY, Util Trail, 4JUUC10123N009757
WA
___
CLASSIFICATION _�
Business
Size
Primary
Covered
RadiusOf
Use
GVW,
Rating
Auto No.S
= service
GCW Or
Age
Factor
Secondary
Except For Towing, All Physical Damage Loss Is Payable
Operation
R =retail
Vehicle
Group
Rating
Code
To You And The Loss Payee Named Below As Interests May
(In Miles)
C =commercial
Seating
Liab.
Phy
Factor
Appear At The Time Of The Loss
Capacity
Dam.
5
S
6
6
6481
6
S
5
69499
7
S
6
6
6481
8
S
6
6
6481
9
S
6
6
6481
10
S
6
01499
11
S
6
6
6481
12
S
6
5
6481
13
S
6
2
6481
14
5
2
69499
POLICY NUMBER:
SCHEDULE OF COVERED AUTOS YOU OWN
EXTENSION OF DECLARATIONS
i r cervi THREE REE . .,i U.4J JLi_ jr 'COVERED AUTOS YOU OVVI'1 (CON'T)
)
A961
(td 7/03)
Covered
Auto No.
COVERAGES —PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any
Column below means that the limit or deductible entry in the corresponding ITEM TWO column applies Instead.)
LIABILITY
rcnauNAL iNJURY
ADDED P.I.P.PROTECTION
PROPERTY PROTECTION
(Michigan Only)
Limit
(In Thousands)
Premium
Limit * Minus
Deductible
Shown Below
Premium
Limit*
Premium
Limit *Minus
Deductible
Shown Below
Premium
5
$ 1,000,000
$ 695
6
$ 1,000,000
7
$ 1,000,000
$ 695
8
$ 1,000,000
$ 695
9
$ 1,000,000
$ 695
10
8 1,000,000
$ 547
11
$ 1,000,000
$ 695
12
$ 1,000,000
$ 695
13
$ 1,000,000
$ 695
14
$ 1,000,000
Total
Premium_•r..
c
$ 5,412
COVERAGES — PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any
Column helnw mans that the limit nr dndnrnhle entry in the corn di.... ITEM TWO col..__ ___lies Instead.) _-_._ sees __ see.._ _.__ _.._ _. ....... entry ........ ......wt..........y ....,., TWO column -applies iiiatcau./
AUTO MEDICALMEDICAL
EXPENSE AND
SPECIFIED
CoveredPAYMENTS
INCOME LOSS BENEFITS
COMPREHENSIVE
CAUSES
COLLISION
TOWING & LABOR
Auto No.
(Virginia Only)
OF LOSS
Limit `**
Limit *i
Limit***
(In
Thousands)
a_ d�,
Premium
Limit **
(In
Thousands)
Premium
Minus
Deductible
Shawn
Premium
Limit***
Premium
Minus
Deductible
Shown
Premium
Limit***
per
disablement
Premium
Below
Below
5
$ 5,000
$ 32
$ 1,000
$ 25
$ 1,000
$ 56
6
$ 1,000
$ 2
$ 1,000
$ 12
7
$ 5,000
$ 32
8
$ 5,000
$ 32
$ 1,000
$ 25
$ 1,000
$ 56
9
$ 5,000
$ 32
$ 1,000
$ 25
$ 1,000
$ 56
10
$ 5,000
$ 39
$ 1,000
$ 46
$ 1,000
$ 104
11
$ 5,000
$ 32
$ 1,000
$ 25
$ 1,000
$ 56
12
$ 5,000
$ 32
$ 1,000
$ 38
$ 1,000
$ 76
13
$ 5,000
$ 32
$ 1,000
$ 49
$ 1,000
$ 100
14
,
Total
premium
$ 263
t' -
_
$ 235
rs�:��.4,;;.�;.
.;fit
$ 516
mit stated in each applicable P.I.P., Added P.I.P, or P.P.I. Endorsement.
** Limit stated in each Medical Expense And Income Loss Endorsement For Each Person
*** Limit stated in ITEM TWO
Page 1
COMMERCIAL AUTO DECLARATION
PKG-DD NEW
Policy_Number
From. 'Folic:Period To °
'Coverage IaiProvided•.By
- Agency.
02CA37837090000
11/01/2005 1 11/01/2006
GRANITE STATE INSURANCE CO.
88292-0491016
'Named insuredAnd_Address
Agent'
The Provident Horizon Group
IRWIN SIEGELAGENCY, INC. (DEV DISABLED)
440 Barnard Blvd
25 LAKE LOUISE MARIE ROAD
P.O. Box 427
ROCK HILL, NY 12775
Sunnyside, WA 98944
AUTO FORMS AND ENDORSEMENTS
FORM NUMBER ED DATE FORM TITLE
78712 08/01 Addendum to Declarations
82001 05/03 Unintentional Failure to Disclose Hazards
86679 08/04 Fellow Employee Exclusion Deleted
86691 09/04 Advisory Notice to Policyholders
86980 11/04 DMV - Important Notice
87146 12/04 Amendatory Endorsement - Coverage Territory
CA0001 10/01 Business Auto Coverage Form
CA0041 03/03 WA - War Exclusion
CA0051 12/04 Changes - Mobile Equipment Subject to Motor Vehicle Insurance Laws
CA0135 10/01 WA Changes
CA2001 10/01 Lessor - Additional Insured & Loss Payee
CA2054 10/01 Employee Hired Autos
CA2134 07/02 WA Underinsured Motorists Coverage
CA2402 12/93 Public Transportation Autos
CA9903 07/97 Auto Medical Payments Coverage
CA9916 12/93 Hired Autos Specified as Covered Auto Form
CA9933 02/99 Employees as Insureds
CA9989 05/01 WA Loss Payable Endorsement
IL0146 11/98 WA Common Policy Conditions
IL0198 09/00 Nuclear Energy Liability Exclusion Endorsement
FORMSCHED (ED. 12/03)
Vehicle Report of Sale
Your transaction of reporting this vehicle as sold has been completed,
Please print this form for your records.
STATE OF WASHINGTON - DEPARTMENT OF LICENSING
Vehicle Report of Sale
Page 1 of 1
PLATE
35268D
I VEHICLE IDENTIFICATION NUMBER
1 FBJS31 M11 HA61 921
I MODEL YR.
1990
MAKE
FORD
I REPORT OF SALE NUMBER
064130305
NAME OF SELLER/TRANSFEROR
CITY OF YAKIMA
NAME OF PURCHASER/TRANSFEREE
TEMPLO BAUTISTA DE YAKIMA
ADDRESS OF SELLER/TRANSFEROR
129 NORTH 2ND STREET
ADDRESS OF PURCHASER/TRANSFEREE
1808 EAST MEAD AVENUE
CITY STATE ZIP CODE
YAKIMA WA 98901 1
CITY STATE ZIP CODE
UNION GAP WA 95993
DATE VEHICLE SOLD
01/13/2006 (
TODAY'S DATE
01/13/2006
SALE PRICE
$500.00
PURCHASER'S DRIVER LICENSE NUMBER
Washington law makes it clear that it is a felony to knowingly make a false statement of fact. (RCW 46.12.210)
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required when there is a change in ownership. This includes, but is not limited to, adding or deleting registered
owner(s), when the vehicle is sold, traded or given as a gift. The transferee/buyer of a vehicle is required to transfer the certificate of
ownership within 15 calendar days, from date of delivery This can be done using the Application for Certificate of Ownership, TD -420-
001, which may be obtained online or from your nearest Vehicle/Vessel Licensing Office Failure to transfer ownership may result in
monetary penalty (RCW 46.12.101)
IMPORTANT - PLEASE READ:
A sellers report does not transfer ownership.
RCW 46.12.101 and 46.55 require that the registered owner of a vehicle notify the Department of Licensing in writing, on the
appropriate form, of the sale or transfer of the vehicle.
A registered owner selling or transferring interest in a vehicle SHALL BE RELIEVED OF PERSONAL LIABILITY FOR
ABANDONED/JUNK VEHICLE TOWING AND STORAGE CHARGES, and shall not be deemed to be the owner of the vehicle SO AS
TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILITY for the operation of the vehicle thereafter by another person WHEN -
1 He/she has made PROPER ENDORSEMENT AND DELIVERY of the Certificates of Ownership and Registration to the
purchaser/transferee
2. He/she has DELIVERED TO THE DEPARTMENT WITHIN FIVE DAYS from the date of delivery, (excluding Saturdays,
Sundays, State and Federal holidays) a "Report of Sale," indicating THE DATE OF DELIVERY, THE NAME AND ADDRESS
OF THE NEW OWNER or transferee, and A DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the
vehicle persuant to the sale or transfer
IMPORTANT. If a Report of Sale has not been submitted to the Department and the new owner has not applied for Certificate of
Ownership and the vehicle is later abandoned, the registered owner will be presumed to have abandoned the vehicle. (RCW 46.63 140)
The seller report of sale document relieves the previous owner of civil and criminal liability only if it is completed in its entirety and
delivered to the de.artment within five da s of the sale of the vehicle RCW 46.12.102
NOTE. The vehicle record will be updated immediately after the data is transferred to our Headquarters Database
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
SELLERS REPORT OF SALE - 1/13/2006 12:52:43 PM
https.//fortress.wa.gov/dol/rosprod/FinalReceiptPrint. asp?P=%14%5C%5B%2D%2D%2C.. 1/13/2006
D. ItS, rn Li k•••,..t-Ir 1%, 1 1.r/I
7•I T Ti 7-7-71,,e.-1 17T Trrt L.
REQLHRED WENEVER. OWNERSHIP CHANGES - U\:Ci..L.FONG DEAL; IRA.0 ES
7,747(77A-(V-V,4-74,7,-""n77.7(Irr(r7:17.,77•71747,4 "'•"4' • •71777:7"77'
1;4
,<41i1
PLEASE PRINT OR TYPE - SEE IMPORTANT INSTRUCTIONS BELOW
LICENSE NUMBER VEHICLE IDENTIFICATION NUMSER (VIN) MODEL YEAR MAK,'
35268D
1FBJS31M1LHA61921
1990
FORD
L
SER/CC
VANPOOL
criRTIFK:AcE NUVRER
0224947802
TRANSFEROR/SELLER: To be reieasea from civil/criminal liability for the 1
operation of the vehicle you rriust fill in this form COMPLETELY The
completed form, MUST be delivered to your local vvashington vehicle license
office, v,Athin 5 days from the date of sale of the ve!-“cie. A service fee
wilt apply.
VST THE DOL
WEBSFE AT:
,,,,'ow wa govidoi
1111
I
I I
III
I
I I
I II
II
L6,,til NAME OF SEI RITRANSFEROR
P.Z.4
(CURRENT REGISTERED CA‘yNER) ''
1
,,.. ,
a NAM - OF PURONASER/TRANSFEREE
,
,. ! •
'4-4 0-13ctak,A-6._. de_ty,k41-042,_
COMPLETE ADDRESS
6k54, I Z:
ir ANS E. 7.1,2
1
6% COMPLETE ADO 1ESS OF PURC,HASERTRANSFEREE
MI
.:'''' ' 1 g 0 t E. cts+- Mead,. Avt_
_ ,
,,1-1 s STA, E ZIP CODE
W
qi? C10 1
CITY A t 4rAt 0 fl,DCge STATE ZIP CODE
Lo -
# 'I
'•;4 .
---tmst-
DATE VENNI( WAS SOLD 1 TODAY'S DATE
1
VEVLEEIJRCHASE PRICE
SELI ,R'S/T . FEROR'S SI;NATURE
Seller: Please DETACH HERE
Seller. Please DETACH HERE
PENALTY FEE FOR LATE TRANSFER
Tiansfer of ownership is iequired when there is a change in ovvnership This includes hon is not limite,d to, adding or deleting registered
owner(s), \A/hen the vehicle is sold, raded Or given as a gift. The tiansiere,eibuyer or a vehicle is r eqt_:;-ed to LansTEir ttie vehicle rierit'icate
of ownersnip within 15 caiendar days, froin date of cielivs7 This can be dome using the Application for Cartirit ate ct Ownershiii)
.031, which may be obtained tnorri the DOL \Nebsite Ci. www wa.00‘v/dol or from your neaies‘ Vehicle Licensing 11710it Failure 0: ri:trisfor
ownership may resuliL 1H1onetary caltliiL pursuant to ER.CAN 0ESL.
sn7E: :It. l7';,:E4t,,J LS'. red - e se zed::
)
2) Detach this :.)ortion arid make CGDy fcii- your reconis. (IMPORTANT. A seller's report does not transfer ownership )
3) Deliver c /our !coal venicie licensing agent. A service fee will
4) ',03 compi52ed ;0:m '`Lr 2St '3E-; tij hie agent It„ 'a -a rdeys 2:
State and Federai holidays)
5) Give tne top portion (released Certif,(J.ate of Ownership) io the buyer, 0 ,nus i a vel-lcts licensing off:0:
transfer ownership
7,C40 46. 2:;1 01 read 46i55 require that the registered OIAMer ef a vehicle nctity the Departmep: of Lcenshws
cn the appropriar.e form, GI,' the sal.s or transfer ofTho vehicie. A registered :Arm& selling or transfemng interest. in a vehicle SHALL
BIE RELIEVED OF PERSONAL LIABILITY FOR ABANDONED/JUNK VEHICLE TOV‘IING AND STORAGE CHAR.O.ES.
shail not be deerned to be the owner of the vehicle SO AS TO BE SUBJECT TO CIVIL OR CRIMINAL LIATLITY for the
operation of the vehicle thereafter by another person WHEN. 1) He/she has made PROPER ENE,'CRSEMENT AND DELNERY
of the Certificates o' Ownership and Registration tote purchaser/transferee 2 Helshe has DELIVERED TO DEP =1.P,Tki ENT
WITHIN FIVE DAYS from the date oF delivery, (excluding Saturdays, Sundays, Stale and Federai hoiidays) a "SE.-Aer's Report
of Sale," indicating THE DATE OF SALE, THE NAME AND ADDRESS OF THE NEVV OWNER or transferee, and A
DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the vehicle pursuant to the sale or transfer
7tAPON7P, if a Seller's Report of Sale., has not been submitted 10 the ciepartrient and the new owner nes not
applied for Certificate of Ownership and the vehicle is later aiDandoned, the registered owner vviil
be presumed to have abandoned the vehe (ROW 46 63
06/01 The Department of Licensing has a policy of providing equal access to rcs services. If you need special accommodation, please call (360) 002-330001 TTY (360) 664-8885.
(STATE)
INSURANCE IDENTIFICATION CARD
COMPANYd7711NUMBER COMPANY
C7AUMBER Mutu F !pniNAcw Ins CO EXPIRATION DATE
YC�PR70047895 08/08/2005 08/08/2006
MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
1990 Ford/EG50 15 Pa 1 FBJS31 M 1 LHA61921
AGENCY / COMPANY ISSUING CARD
Argus Insurance, Inc.
415 N. 2nd Street (509)248-2672
P. 0. Box 2945 (98907)
MetiaIlta, WA 98901
Templo Bautista Church
1808 East Mead Avenue
Union Gap, WA 98903
SEE IMPORTANT NOTICE ON REVERSE SIDE
(360 664-1490
Domestic Nonprofit Corporation
Unified Business ID #: 601 457 661
Business ID #: 1
Location: 1
TEMPLO BAUTISTA DE YAKIMA
1808 E MEAD
UNION GAP WA 98903
TAX REGISTRATION UNEMPLOYMENT INSURANCE
INDUSTRIAL INSURANCE
REGISTERED TRADE NAMES:
TEMPLO BAUTISTA DE YAKIMA
The licensee named above has been issued the business registrations or
licenses listed. By accepting this document the licensee certifies the information
provided on the application for these licenses was complete, true, and accurate
to the best of his or her knowledge, and that business will be conducted in
compliance with all applicable Washington state, county, and city regulations.
Director, Department of Licensing
SSF 9 (R 2/92)
PAGE 1 OF 2
Corporations Division
r1� tk 1 1.4 Office of the Secretary of State
QF ���ASN1l1G 505 E. Union, 2nd Floor
$'(A� t �9�� PO BOX 40234
^^k 2 - Olympia, WA 98504-0234
�H 1.4110 Information. (206) 753-7115
RA1.Pp•.
ur.r^
-ertICT
CORPORATION
OF INCORPORATION
a corporation under the nonprofit laws of the State of Washington,
Articles of Incorporation:
ARTICLE I
TEMPLO BAUTISTA de YAKIMA
,tv, 51 re�
(~�'(1T21�� jre'�'�" a f
J ci�t.i
�LJa.-iv
=
Of STATEIcy y�?
1849 a
NONPROFIT
ARTICLES
The undersigned, for the purpose of forming
RCW 24.03, hereby adopts the following
The name of the corporation shall be:
The term of existence shall be: (check only
The purposes for which the corporation is
THIS CONGREGATION IS ORGANIZED
ARTICLE II
one box) G! perpetual ❑ (number of) years
ARTICLE III
organized are as follows -
AS A CI -LURCH EXCLUSIVELY CHARITABLE, RELIGIOUS AND
EDUCATIONAL PURPOSES WITHIN THE MEANING OF SECTION 501(C) (3) OF THE INTERNAL
REVENUE CODE OF 1986, INCLUDING, BUT NOT LIMITED TO, FOR SUCH PURPOSES, THE ESTABLISHD
AND MAINTAINING OF RELIGIOUS WORSHIP, THE BUILDING, MAINTAINING AND OPERATING OF CHURCE
PARSONAGES, SCHOOLS, CHAPELS, RESCUE MISSIONS, PRINT SHOPS, DAYCARE CENTERS, CAMPS,
NURSING HOMES, AND ANY OTHER MINISTRIES
The name of the Registered Agent of the
The street address of the Registered Office,
Number and Street 1808 E. MEAD
THAT THE CHURCH MAY BE LED OF GOD TO ESTABLISH.
ARTICLE N
corporation is: JOSE M. RAMOS
which is also the address of the Registered Agent is as follows
AVENUE
City UNION GAP , WA Zip Code 98903
The post office box number, which may be used in conjunction with the Registered Agent address, located in the
same city, is:
PO Box # k City WA Zip Code
,
SSF 9 (R 2/92)
PAGE 1 OF 2
TEMPLO BAUTISTA DE YAKIMA
Yakima, WA. December 28, 2005
Yakima Transit Department.
TO WHOM IT CORRESPONDS:
I, Jose M. Ramos, pastor of I'EMPLO BAUTISTA DE YAKIMA, authorize to Jose G. Gonzalez, to pick
up the van that was assignees to our church.
I understand that this will be January 3rd. of 2006.
Thank vs>u and God Bless You.
Pastor
;Ramos
St
1808 E MEAD AVE • UNION GAP, WA • 98903
PHONE. 509-575-4607
Vehicle Report of Sale
Page 1 of 1
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
STATE OF WASHINGTON - DEPARTMENT OF LICENSING
Vehicle Report of Sale
IPLATE
n44U,lE
I VEHICLE IDENTIFICATION NUMBER
1 FR_IS31 lytXl HA61920
I MODEL YR.
199n
MAKE
FORD
I REPORT OF SALE NUMBER
064130315
NAME OF SELLER/TRANSFEROR
CITY OF YAKIMA
NAME OF PURCHASER/TRANSFEREE
STONE CHURCH
ADDRESS OF SELLER/TRANSFEROR
129 NORTH 2ND STREET
ADDRESS OF PURCHASER/TRANSFEREE
3303 ENGLEWOOD AVENUE
CITY STATE ZIP CODE
1 YAKIMA WA 98901
CITY STATE ZIP CODE
YAKIMA WA 95902
' DATE VEHICLE SOLD TODAY'` DATE
J
101 /04/2006 101 /13/2006
S... o
�J.YLE PRICE
I $500.00
P.
PURCHASER'S DRIVER LICEfVJE NUMBER
Washington law makes it clear that it is a felony to knowingly make a false statement of fact. (RCW 46.12.210)
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is required when there is a change in ownership This includes, but is not limited to, adding or deleting registered
owner(s), when the vehicle is sold, traded or given as a gift. The transferee/buyer of a vehicle is required to transfer the certificate of
ownership within 15 calendar days, from date of delivery This can be done using the Application for Certificate of Ownership, TD -420-
001, which may be obtained online or from your nearest Vehicle/Vessel Licensing Office Failure to transfer ownership may result in
monetary penalty. (RCW 46 12.101)
IMPORTANT - PLEASE READ:
A seller's report does not transfer ownership.
RCW 46.12.101 and 46.55 require that the registered owner of a vehicle notify the Department of Licensing in writing, on the
appropriate form, of the sale or transfer of the vehicle.
A registered owner selling or transferring interest in a vehicle SHALL BE RELIEVED OF PERSONAL LIABILITY FOR
ABANDONED/JUNK VEHICLE TOWING AND STORAGE CHARGES, and shall not be deemed to be the owner of the vehicle SO AS
TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILITY for the operation of the vehicle thereafter by another person WHEN -
1 He/she has made PROPER ENDORSEMENT AND DELIVERY of the Certificates of Ownership and Registration to the
purchaser/transferee
2. He/she has DELIVERED TO THE DEPARTMENT WITHIN FIVE DAYS from the date of delivery, (excluding Saturdays,
Sundays, State and Federal holidays) a"Report of Sale," indicating THE DATE OF DELIVERY, THE NAME AND ADDRESS
OF THE NEW OWNER or transferee, and A DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the
vehicle persuant to the sale or transfer
IMPORTANT If a Report of Sale has not been submitted to the Department and the new owner has not applied for Certificate of
Ownership and the vehicle is later abandoned, the registered owner will be presumed to have abandoned the vehicle. (RCW 46 63 140)
The seller report of sale document relieves the previous owner of civil and criminal liability only if it is completed in its entirety and
delivered to the de.artment within five da s of the sale of the vehicle. RCW 46.12.102
NOTE. The vehicle record will be updated immediately after the data is transferred to our Headquarters Database.
Your transaction of reporting this vehicle as sold has been completed.
Please print this form for your records.
SELLERS REPORT OF SALE - 1/13/2006 12:59:54 PM
https://fortress.wa.gov/dol/rosprod/FinalReceiptPrint.asp?P=%14%29%2E%29%5F%2D% . 1/13/2006
Vehicle Infoimation
Page 1 of 1
Vehicle Information
VIN 1 FBJS31 MXLHA61920
Model Year 1990
Make FORD
Series/Body VAN POOL
NOTE: Plate 35257D has been replaced by plate 044UJE
Please verify the vehicle information before continuing
SELLERS REPORT OF SALE - 1/13/2006 12:48:12 PM
https://fortress.wa.gov/dol/rosprod/DisplayVeh.asp?P=%14%5D%5BV%5D%2AW%2B%2AB%2AZ%5B %5EB%5B%2E%2... 1/13/2006
REQURED WHENEVER 0Vii7NER,Si-i? CHANC;ES CLJ\0 0E
7,77pIrr.7,737.77,7,77707,mtirtvir,„L,;,„,,,,,,z
r.griattitiiig-1.01%2),WA.F4ia, .
PLEASE PRINT OR TYPE - SEE IMPORTANT INSTRUCTIONS BELOW
ER "E'RAriRS
77,7
LICENSE NUMBER
VEHICLE ?CENT IFICATION D(ISER (VIN) MODEL Y.- ^(P
35257D 1FBJS31MXLHA61920 1990
FTRANSFEROR/SELLER. To be released from civil/criminal liability for
operation of the vehicle you must 111 in this rorm COMPLETELY The
completed form MUST be delivered to your local washington vehicle license
office wff.hin 5 days froro the c,'ath of s,,74e of the vehicie... A service. fee
wil; appy
447 NAM OF SELLER/TRANSFEROR (CURRENT REGISTERED OWNER)
TODAY'S DATE
Seller Please DETACH HERE
STATE ZIP CODE
CIFNO I
VF CLE PURCHASE PRICE
41) _CO
I(E'
'
02E_ •,),',E
CERIESISODY 'ERTIFIC E VIIMSEP
FORD VANPOOL 0224848007
\4,9316" THE DOL
WEBE7E AT
wiwrimAive-go°,,/do
111111111
NAME.42..HASERITRP vcc)r\
A COMPLETE ADDRE S OF PI CHASER/TRANSFEREE
AL -
FPRO
tJ (c.§
STATE
Seller Please DETACH HERE
PENALTY FEE FOR LATE TRANSFER
Transfer of ownership is reguired when there is a change in ownership This includes, INJI, not limited to, adding or deleting registered
owner(s), when the ve,h;cle is sold, traded or given as a gift. The transferee/buyer of a vehicle is required to transfer the vehicle certificate
of ownership within 15 calendar days, from date of delivery This oar, be dome using this 8,,,collootion for Certificate of Ownersnin, TD -,412n-
001, whichi may be obtained From the DOL Website at www wa.gov/dol or From your nearest 'vehicle Licensin, Office Faliure to transfer
„r_ownershiip may result in monetary penalty_pursuani to RCW 46 12.101L6)_
31)
I(7 )
'Ci," , L L I) ',,,(7;),h L ..2- D, DV ID ',..!'
FID( -7, : 7r.Li C r : r,7c,T zi:•i= ,3,5,i Jtitt.:Ili Th itoiriti,THI, r',''.0,T111.•,''f -;',F '71' ''.1:: ', (.1, 1(11 ,,i'11 .7'77 '7 '-' 17 ' P.?i'a '
Detach this coriion and. make a copy for vour records (IMPORTANT A seller's report does not transfer ownership )
De.iver to your local tiehicle Iicer eibciI agent. A sei irice ne win eopiv
-he SO ierlp eter fra,PT "T't ..,,t.f.S be rt,ictei,iviti.,c' by the, lib a s ng-
State and Federal holidays)
the tor pcFrjon (reHased. CeituIc ,Ae DI:'aalME.'i-Sni3 , .-,' 'ie I.iiiye,- iiictic tii_sit I.,-,t,e it 1.0 2 v',: -:h3. i-:.'3nSir,-J Cir-TiC5 to
transfer ownersnip
RCIltlY , 52101 and .t'f3.55 ,-Squire th,., .t.:`s. -acqstared c;477:er cf a YeNc.is iectifi ilhe Dopactrlsr,t of Lireils,'/T /c, ,"•'-g',2'
ion the 2:.:1:,,rocrate form, of the sa:feor t:a;Iiii,tte:-nif tr-te vehti.e. A registe-red owner selling Or traTisferringi interest ir a vehicla; SHALL
SE RELIEVED CF PERSONAL LABILITY FOR ABANDONED/ jUNK VEHICLE TOWING A,ND ST-tiRA GE CHARGES and
shall not be deemed to be the owner of the vehicle SO AS TO BE SUBJECT TO CIVIL OR CRIMINAL LIABILIT'it for the
operation of the vehicle thereafter by another person WHEN 1) He/she has made PROPER ENDORSEMENT AND DE -LIVERY
of the Certificates ci, Ownership and Registration to the purchaser/transferee 2) He/She has DELIVERED Tr) THE DEPAPTMENT
WITHIN FIVE DAYS from the date of delivery, (excluding Saturdays. Sundays, State and Federal holidays) a "Seller's Report
of Sale " indicating THE DATE OF SALE. THE NAME AND ADDRESS OF THE NEW OWNER or transferee, and A
DESCRIPTION of the vehicle, or PROPER DOCUMENTS for registration of the vehicle pursuant to the sale or transfer
.
—_, -----,
rnAPORTANT: if a Seller's Report of Sale has not been submitted to the department and the neiiiv owner has not
applied for Certificate of Ownership and the vehicle is later e,bandoned, the rerred owner will
be presumed to have abandoned the vehicle (RCW 46 63 140)
__-----_—_--_,— -----,_ i
06/01 The Department of Licensing has a policy of providing equal access to its services If you need special accommodation, please call (360) 902-3600 o TTY (360) 664-3885.
�gUMryC
Mutual of le Enumclaw
Nig"
1460 Wells Street, Enumclaw, WA 98022
Commercial Policy
Common Policy Declarations
POLICY NUMBER: CP40046593
This policy is a RENEWAL
Named Insured:
STONE CHURCH INC
3303 ENGLEWOOD AVE
YAKIMA WA 98902
Agency:
WHITFIELDS UNITED INS AGENCIES
Phone No. (425) 258-2300 Code # 6592
Policy Period: From: 12/06/2005 to 12/06/2006
12:01 A.M. Standard Time at your mailing address shown above.
at
Form of Business: ASSOCIATION Type of Business: Rel i g i ous Organizations
IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THIS
POLICY WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
This Policy Consists of the Following Coverage Parts For Which A Premium Is Indicated. This Premium May Be Subject to Adiustm
Coverage Part
As Provided by
Declarations
premium
Commercial Property Coverage Part
$ NO COVERAGE
Commercial General Liability Coverage Part
$ NO COVERAGE
Commercial Inland Marine Coverage Part
$ NO COVERAGE
Commercial Crime Coverage Part
$ NO COVERAGE
Commercial Auto Coverage Part
DA 00 93 0194
$ 6,856
Farm Coverage Part
$ NO COVERAGE
$
$
TOTAL
$ 6,856.00
Total includes Terrorism Coverage Premiums for:
Mandatory Terrorism Coverage
Optional Terrorism Coverages
Not Applicable
$ 0 .00
Premium Due At Inception:
THIS IS NOT A BILL.
Please Refer to Account Billing For Any Payment Information.
THIS POLICY IS SUBJECT TO AUDIT
Forms Which Describe or Modify The Coverages Provided By This Insurance Are Listed On The Coverage Part Declarations Pages For
Which They are Applicable. All Such Forms Are Attached To And Are A Part Of This Policy. Please Read Your Policy Carefully.
Countersigned:
(Date)
DP 00 93 0103 INSURED COPY
By:
(Authorized Representative)
Page 1 of 2
Mutual of Enumclaw Insurance Company Enumclaw, Washington 98022
COMMERCIAL POLICY COMMON POLICY DECLARATIONS - CONTINUED
Named Insured: STONE CHURCH INC
Policy Number: CP40046593
COMMON POLICY SCHEDULE OF LOCATIONS
Loc
No.
Bldg.
No.
Description or Address
DP 01
93
NOT APPLICABLE FOR AUTOMOBILES
COMMON FORMS AND ENDORSEMENTS SCHEDULE
THE FOLLOWING FORMS OR ENDORSEMENTS APPLY TO ALL COVERAGE PARTS INCLUDED ON THE POLICY.
Form Number
Form Name
DP 01
93
0194
MUTUAL POLICY CONDITIONS
IL 00
21
1185
NUCLEAR ENERGY LIABILITY EXCLUSION
ME 46
01
0194
COMMON POLICY CONDITIONS - WASHINGTON
Page 2 of 2
Dn raft ®.4 11.1 ftq
r vv a.a 1.0 Iva
•
COMMERCIAL AUTO
CA00011293
BUSINESS AUTO COVERAGE FORM
Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties
and what is and is not covered.
Throughout this policy the words "you" and "your" refer to the Named Insured shown in the Declarations.
The words "we", "us" and "our" refer to the Company providing this insurance.
Other words and phrases that appear in quotation marks have special meaning. Refer to SECTION V -
DEFINITIONS.
SECTION 1- COVERED AUTOS
ITEM TWO of the Declarations shows the "autos"
that are covered "autos" for each of your coverages.
The following numerical symbols describe the
"autos" that may be covered "autos". The symbols
entered next to a coverage on the Declarations
designate the only "autos" that are covered "a utos
A. DESCRIPTION OF COVERED AUTO DESIG-
NATION SYMBOLS
SYMBOL DESCRIPTION
1 = ANY "AUTO".
2 = OWNED "AUTOS" ONLY. Only those
"autos" you own (and for Liability Cov-
erage any "trailers" you don't own while
attached to power units you own). This
includes those "autos" you acquire own-
ership of after the policy begins.
= OWNED PRIVATE PASSENGER
"AUTOS" ONLY. Only the private pas-
senger "autos" you own. This includes
those private passenger "autos" you ac-
quire ownership of after the policy be-
gins.
4 = OWNED "AUTOS" OTHER THAN PRI-
VATE PASSENGER "AUTOS" ONLY.
Only those "autos" you own that are not
of the private passenger type (and for
Liability Coverage any "trailers" you
don't own while attached to power units
you own). This includes those "autos"
not of the private passenger type you
acquire ownership of after the policy
begins.
5 = OWNED "AUTOS" SUBJECT TO NO-
FAULT. Only those "autos" you own that
are required to have No -Fault benefits in
the state where they are licensed or prin-
cipally garaged. This includes those
"autos" you acquire ownership of after
the policy begins provided they are re-
quired to have No -Fault benefits in the
state where they are licensed or princi-
pally garaged.
3
CA 00 01 12 93
6 = OWNED "AUTOS" SUBJECT TOA COM-
PULSORY UNINSURED MOTORISTS
LAW. Only those "autos" you own that
because of the law in the state where
they are licensed or principally garaged
are rer,iiireri to have and cannot refect
Uninsured Motorists Coverage. This in-
cludes those "autos" you acquire owner-
ship of after the policy begins provided
they are subject to the same state unin-
sured motorists requirement.
7 = SPECIFICALLY DESCRIBED "AUTOS".
Only those "autos" described in ITEM
THREE of the Declarations for which a
premium charge is shown (and for Lia-
bility Coverage any "trailers" you don't
own while attached to any power unit
described in ITEM THREE).
8 = HIRED "AUTOS" ONLY. Only those
"autos" you lease, hire, rent or borrow.
This does not include any "auto" you
lease, hire, rent, or borrow from any of
your employees or partners or members
of their households.
9 = NONOWNED "AUTOS" ONLY. Only
those "autos" you do not own, lease,
hire, rent or borrow that are used in
connection with your business. This in-
cludes "autos" owned by your employ-
ees or partners or members of their
households but only while used in your
business or your personal affairs.
B. OWNED AUTOS YOU ACQUIRE AFTER THE
POLICY BEGINS
1. If symbols 1, 2, 3, 4, 5 or 6 are entered next
to a coverage in ITEM TWO of the Declara-
tions, then you have coverage for "autos"
that you acquire of the type described for
the remainder of the policy period.
Copyright, Insurance Services Office, Inc., 1993 Page 1 of 12
111
2. But, if symbol 7 is entered next to a coverage
in ITEM TWO of the Declarations, an "auto"
you acquire will be a covered "auto!! for that
coverage only if:
a. We already cover aii "autos" that you
own for that coverage or it replaces an
"auto" you previously owned that had
that coverage; and
b. You tell us within 30 days after you ac-
quire it that you want us to cover it for
that coverage.
C. CERTAIN TRAILERS, MOBILE EQUIPMENT
AND TEMPORARY SUBSTITUTE AUTOS
If Liability Coverage is provided by this Cover-
age Form, the following types of vehicles are
also covered "autos!! for Liability Coverage:
A. COVERAGE
1. "Trailers" with a load capacity of 2,000
pounds or less designed primarily for travel
on public roads.
L_!..-. J
2. "Mobile equipment"whiie being carried or
1J "auto".
towed by a covered .
3. Any "auto" you do not own while used with
the permission of its owner as a temporary
substitute for a covered "auto" you own that
is out of service because of its:
a. Breakdown;
b. Repair;
c. Servicing;
a. "Loss"; or
e. Destruction.
SECTION ION II - LIABILITY Y COVERAGE
We will pay all sums an "insured!! legally must
pay as damages because of "bodily injury!! or
"property damage" to which this insurance ap-
plies, caused by an "accident!! and resulting
from the ownership, maintenance or use of a
covered "auto".
We will aiso pay aii sums an "insured" legally
must r av as a !"covered pollution cost or ex-
penseto which this insurance applies, caused
by an "accident" and resulting from the owner-
ship, maintenance or use of covered "autos".
However, we will only pay for the "covered pol-
lution cost or expense"! if there is either "bodily
injury" or "property damage" to which this in-
surance applies that is caused by the same
"accident".
We have the right and duty to defend any "in-
sured!! against a "suit" asking for such damages
or a "covered pollution cost or expense". How-
ever, we have no duty to defend any "insured"
against a "suit" seeking damages for !`bodily
injury" or "property damage" or a "covered pol-
lution cost or expense11 to which this insurance
does not apply. We may investigate and settle
any claim or "suit" as we consider appropriate.
Our duty to defend or settle ends when the
Liability Coverage Limit of Insurance has been
exhausted by payment of judgments or settle-
ments.
Page 2 of 12
1. WHO IS AN INSURED
The following are "insureds":
a. You for any covered "auto".
b. Anyone else while using with your per-
mission a covered "auto" you own, hire
or borrow except:
(1) The owner or anyone else from
whom you hire or borrow a covered
"auto)!. This exception does not
apply if the covered "auto" is a
"trailer" connected to a covered
"auto" you own.
(2) Your employee if the covered "auto!!
is owned by that employee or a
member of his or her household.
(3) Someone using a covered "auto"
while he or she is working in a busi-
ness of selling, servicing, repairing,
parking or storing "autos!" unless
that business is yours.
(4) Anyone other than your employees,
partners, a lessee or borrower or any
of their employees, while moving
property to or from a covered
"auto".
Copyright, Insurance Services Office, Inc., 1993, 1994 CA 00 01 12 93
•
•
•
n
U. S. TREASURY DEPARTMENT
INTERNAL REVENUE SERVICE
WASHINGTON 25. D. C.
AUG 311964
General Council of the Assemblies
of God
"'MI5 Boonville Avenue
Springfield, Missouri 65802
Gentlemen:
M REPLY REFER TO
T:R:EO:5
JJF
We have considered your request for a group ruling holding
your subordinate units exempt from Federal income tax as organ-
izations described in section 501(c)(3) of the Internal Revenue
Code of 1954.
Our records disclose that you were held exempt from Federal
income tax under section 231(6) of the Revenue Act of 1921 on
April 15, 1922. On September 14, 1935 you were held exempt under
section 101(6) of the Revenue Act of 1934, which ruling was af-
firmed under the Revenue Act of 1936 on April 27, 1938. On
September 20, 1955 the District Director held that since sec-
tion 501(c)(3) of the 1954 Internal Revenue Code contains the
same provisions as section 101(6) of the prior Revenue Acts,
previous rulings are held to be applicable under the 1954 Code.
Based upon the information presented, it is held that your
subordinate departments, district councils, churches, institu-
tions, organizations, schools and colleges, whose names appear
in your Directory, revised to January 1, 1964, are exempt from
Federal income tax as organizations described in section 501
(c')(3) of the Internal Revenue Code of 1954 as it is shown that
they are organized and operated exclusively for religious pur-
poses.
You and your subordinate units are not required to file
Federal income tax returns so long as a tax exempt status is
'< maintained.
It will not be necessary for you and your subordinate units
to file the annual information return, Form 990-A, generally re-
quired of organizations exempt under section 501(c)(3) of the
Code, as the specific exceptions contained in section 6033(a) of
the Code are applicable.
RECEIVED
SEP 31964
GENERAL SECRETARY'S
OFFICE
�'�'�fashington, D.C. 20224
Date:
vGldal 1.111G111. VI UIG 1 1 GClow y
Person to Contact:
Mr. Charles E. McLaughlin
Telephone Number:
(202)964-6197
44-0577787. 1678 06 06 03 Refer Reply to:.
I> C, ENERAL COUNCIL or THE ASSEMBLIES OF E:E0:0:R
114445 bOONVILLE AVENUE Date:
S PRI NGF I ELI) MO 65802 February 17, 1976
roup Exemption Numl
Dear Officer or Trustee:
_ . 67Jy8_�
.j. i� Y a` l //
We are contacting all because �uc..�r�g group central organizations "the 1975 Form 990 and
instructions require each central organization and its subordinates to show their
1
group exemption number (GEN) in Part I, item 18(b), of Form 990.
Your group exemption number is shown above. Please advise any of your subordi-
nates that are required to file an annual information return, Form 990, to place
your group exemption number on their return.
Cturrt central organizations are .o.t.xequired to file an annual information
return: However, any of their subordinates that do not qualify as "integrated
au iaries" of a church are required to file an information return, Form 990, and
should include on that return the appropriate group exemption number. We are
preparing a proposed amendment to the Income Tax Regulations which will define an
integrated auxiliary of a church. When that amendment is published, we will send an
information copy to holders of group exemption rulings under section 501(c)(3) of the
Internal Revenue Code. (Organizations exempt under other provisions will not
receive a copy-)
If you have any questions, please contact the person whose name and telephone
number are shown above.
Thank you for your help in this matter.
Sincerely yours,
. Tedesco, Director
mpt Organizations Division
M-0088 (2-76)