Report (29) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
ient: Reimbursement District Payment Worksheet
y Wo s eet
IN
i c; ,E; i) 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503.718.2439 • www.tigard-or.gov
This completed worksheet is to be submitted along with payment for sewer
connection and plumbingpermit application by expiration date below
ENGINEERING TO COMPLETE:
Site Address: 75/0 sli/ Chte0Y Pie
Reimbursement District #: if 9 Parcel #: 2.9 IOI DCO 1800
Amount Due: $ f 7-t v.2.51 (o{, Amount Due Expires On: Wo y 2-3,20/8
Applicant: Ko,fe,r r x g,anAali Daytime Phone: 5.°3 - G7 7 - 7957
❑ Sewer Loan Processed (journal entry to follow for payment)
Deferred Accounts (if applicable):
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agreement (signed prior to completion of worksheet)
By: 1st.,•..4 e. tR4_ Date: i-/0 -204
BUILDING TO COMPLETE:
Reimbursement Amount Paid: $ 1 7l 7,Z5 6.6, Receipt #: '7'/c153
SWR #: 54.»2.20!f-0003, PLM #: /%/L/,ZO/F-POO `/,3
Enter parcel conditions in Accela (check all that apply):
[4 Enter "paid" condition.
❑ Enter "deferral" condition,if applicable.
By: yezz'..,
4ij Date: I 7/l
Attach 's worksheet to sewer permit for records scanning.
IABuilding\Riembursement Districts\ReimDistPaymentWorksheet__021014.docx