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County of Fairfax, Virginia

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County of Fairfax, Virginia County of Fairfax, Virginia MEMORANDUM Office of the County Attorney Suite 549, 12000 Government Center Parkway Fairfax, Virginia 22035-0064 Phone: (703) 324-2421; Fax: (703) 324-2665 www.fairfaxcounty.gov DATE: September 19, 2019 TO: Sharon Williams, Staff Coordinator Zoning Evaluation Division Department of Planning and Zoning FROM: Jo Ellen Groves, Paralega Office of the County Attorney SUBJECT: Affidavit Application No.: PCA/CDPA/FDPA 74-7-047-02-02 Applicant: Inova Health Care Services PC Hearing Date: 10/2/19 BOS Hearing Date: 10/15/19 REF.: 149227 Attached is an affidavit which has been approved by the Office of the County Attorney for the referenced case. Please include this affidavit dated 9/18/19, which bears my initials and is numbered 149227a, when you prepare the staff report. Thank you for your cooperation. Attachment cc: (w/attach) Julia Nichols, Planning Technician I (Sent via e-mail) Zoning Evaluation Division Department of Planning and Zoning \\SI 7PROLAWPGC01 \Documents\ 149227 \JEG \Affidavits\ 1224630.docx REZONING AFFIDAVIT 11-Ki2Z:rct. DATE: September 18, 2019 (enter date affidavit is notarized) 1, Timothy S. Sampson, Esq. , do hereby state that I am an (enter name of applicant or authorized agent) (check one) [ applicant [v] applicant's authorized agent listed in Par. 1(a) below in Application No.(s): PCA 74-7-047-02-02/CDPA 74-7-047-02-02/FDPA 74-7-047-02-02 (enter County-assigned application number(s), e.g. RZ 88-V-001) and that, to the best of my knowledge and belief, the following information is true: 1(a). The following constitutes a listing of the names and addresses of all APPLICANTS, TITLE OWNERS, CONTRACT PURCHASERS, and LESSEES of the land described in the application,*and, if any of the foregoing is a TRUSTEE,**each BENEFICIARY of such trust, and all ATTORNEYS and REAL ESTATE BROKERS, and all AGENTS who have acted on behalf of any of the foregoing with respect to the application: (NOTE: All relationships to the application listed above in BOLD print must be disclosed. Multiple relationships may be listed together, e.g., Attorney/Agent, Contract Purchaser/Lessee, Applicant/Title Owner, etc. For a multiparcel application, list the Tax Map Number(s) of the parcel(s) for each owner(s) in the Relationship column.) NAME ADDRESS RELATIONSHIP(S) (enter first name, middle initial, and (enter number, street, city, state, and zip code) (enter applicable relationships last name) listed in BOLD above) Inova Health Care Services 8110 Gatehouse Road, Suite 200 Applicant/Ground Lessee ("Owner" by East Tower virtue of a ground lease in excess of 30 Agents: Falls Church, Virginia 22042 years) of Tax Map 49-4 ((1)) 57 J. Stephen Jones Alice H. Pope John F. Gaul Jennifer W. Siciliano H. Patrick Walters II. Thomas MeDuffie Johnny F. Weaver K. Ashley Hunnicutt Dominic J. Bonaiuto Kelly A. Schlageter Michael D. Forehand (check if applicable) [v] There are more relationships to be listed and Par. 1(a) is continued on a "Rezoning Attachment to Par. 1(a)" form. * In the case of a condominium, the title owner, contract purchaser, or lessee of 10% or more of the units in the condominium. ** List as follows: Name of trustee, Trustee for (name of trust, if applicable), for the benefit of: (state name of each beneficiary). FORM RZA-1 Updated (7/1/06) Pagel of 2 Rezoning Attachment to Par. 1(a) DATE: September 18, 2019 11+c? 2-27 cz (enter date affidavit is notarized) for Application No. (s): PCA 74-7-047-02-02/CDPA 74-7-047-02-02/FDPA 74-7-047-02-02 (enter County-assigned application number (s)) (NOTE: All relationships to the application are to be disclosed. Multiple relationships may be listed together, e.g., Attorney/Agent, Contract Purchaser/Lessee, Applicant/Title Owner, etc. For a multiparcel application, list the Tax Map Number(s) of the parcel(s) for each owner(s) in the Relationship column. NAME ADDRESS RELATIONSHIP(S) (enter first name, middle initial, and (enter number, street, city, state, and zip code) (enter applicable relationships last name) listed in BOLD above) ExxonMobil Foundation do ExxonMobil Environmental and Property Fee Title Owner of Tax map 49-4(1)) 57 Agents: Solutions Company Kevin W. Murphy Attn: Commercial Portfolio Manager Hugh Corner Wellness 3, 2B. 481 John L. Rudisill 22777 Springwoods Village Pkwy Becky J. Wiley; Maria M. Quezada Spring, Texas 77389 M.J. Wells & Associates, Inc. 1420 Spring Hill Road, Suite 610 Transportation Consultant/Agents Agents: Tysons, Virginia 22102 William F. Johnson Kevin R. Fellin Andrew C. Buntua Brian J. Horan Lester E. Adkins christopher consultants, ltd. 9900 Main Street, Suite 400 Engineers, Planners, Agents Agents: Fairfax, Virginia 22031 William R. Zink John L. Helms Kevin M. Washington John Rinaldi Jana Morgan Wetland Studies and Solutions, Inc. 5300 Wellington Branch Drive, Suite 100 Environmental Consultants/Agents Agents: Gainesville, VA 20155 Mark Headly (check if applicable) [v] There are more relationships to be listed and Par. 1(a) is continued further on a "Rezoning Attachment to Par. 1(a)" form. FORM RZA-1 Updated (7/1/06) Page 2 of 2 Rezoning Attachment to Par. 1(a) DATE: September 18, 2019 ;ffcl (enter date affidavit is notarized) for Application No. (s): PCA 74-7-047-02-02/CDPA 74-7-047-02-02/FDPA 74-7-047-02-02 (enter County-assigned application number (s)) (NOTE,: All All relationships to the application are to be disclosed. Multiple relationships may be listed together, e.g., Attorney/Agent, Contract Purchaser/Lessee, Applicant/Title Owner, etc. For a multiparcel application, list the Tax Map Number(s) of the parcel(s) for each owner(s) in the Relationship column. NAME ADDRESS RELATIONSHIP(S) (enter first name, middle initial, and (enter number, street, city, state, and zip code) (enter applicable relationships last name) listed in BOLD above) Sittler Development Associates, LLC 1768 Business Center Drive, Suite 340 Consultant, Agent Agent: Reston, Virginia 20190 J. David Sittler Downs Raehlin Martin PI,I,C 199 Main Street PO Box 190 Attorney, Agent Agent: Burlington. Vermont 05402 Timothy S. Sampson RLAntonucci, LLC 9576 Sunnyslope Drive Transportation Consultant. Agent Agent: Manassas, Virginia 20112 Robin L. Antonucci Hellmuth, Obata & Kassabaum, PC 10 South Broadway, Suite 200 Architects, Agent Agents: St. Louis, MO 63102 Suzette Goldstein Erica Thum John Wray IV Dewberry Engineers Inc. 8401 Arlington Blvd Engineers, Planners, Agents Agents: Fairfax, Virginia 22031 David Mahoney Jeremy J. Beck Gensler Architecture, Design & Planning, 2020 K Street, NW Architects, Agent P.C. Washington, D.C. 20006 Agent: Tama Duffy Day Tripp Umbach, Inc. 1903 W 8th St Pmb #111 Economic Advisors/Agents Agent: Erie, PA 16505 Paul Umbach (check if applicable) [ ] There are more relationships to be listed and Par. 1(a) is continued further on a "Rezoning Attachment to Par. 1(a)" form. FORM RZA-1 Updated (7/1/06) Page Two REZONING AFFIDAVIT DATE: September 18, 2019 (enter date affidavit is notarized) for Application No. (s): PCA 74-7-047-02-02/CDPA 74-7-047-02-02/FDPA 74-7-047-02-02 (enter County-assigned application number(s)) 1(b). The following constitutes a listing***of the SHAREHOLDERS of all corporations disclosed in this affidavit who own 10% or more of any class of stock issued by said corporation, and where such corporation has 10 or less shareholders, a listing of all of the shareholders, and if the corporation is an owner of the subject land, all of the OFFICERS and DIRECTORS of such corporation: (NOTE: Include SOLE PROPRIETORSHIPS, LIMITED LIABILITY COMPANIES, and REAL ESTATE INVESTMENT TRUSTS herein.) CORPORATION INFORMATION NAME & ADDRESS OF CORPORATION: (enter complete name, number, street, city, state, and zip code) Inova Ifealth Care Services 8110 Gatehouse Road, Suite 200, East Tower Falls Church, Virginia 22042 DESCRIPTION OF CORPORATION: (check one statement) [ There are 10 or less shareholders, and all of the shareholders are listed below. [ There are more than 10 shareholders, and all of the shareholders owning 10% or more of any class of stock issued by said corporation are listed below. There are more than 10 shareholders, but no shareholder owns 10% or more of any class of stock issued by said corporation, and no shareholders are listed below. NAMES OF SHAREHOLDERS: (enter first name, middle initial, and last name) Inova Health Care Services, formerly Inova Health System Hospitals, formerly Inova I lospitals, formerly Fairfax I Iospital System, Inc., formerly Fairfax Hospital Systems, Inc., formerly Fairfax Hospital Association, is a non-stock, non-profit corporation, the sole member of which is Inova Health System Foundation. Inova Health System Foundation appoints the Board of Trustees of Inova Ifealth Care Services NAMES OF OFFICERS & DIRECTORS: (enter first name, middle initial, last name & title, e.g. President, • Vice President, Secretary, Treasurer, etc.) Officers: J. Stephen Jones, President; Jack Ebeler, Chairman; Charles Beard Jr., Secretary; John F. Gaul, Asst Secretary; Alice H. Pope, CFO/Treasurer -- Board of Trustees: Charles E. Beard Jr., John Cook, Jack EbelerPhillip Nolan, Keith Sterling, Robert Tsien, Janis Caruso, Lucas Collazo, John F. Gaul, Scott Ifamberger, J. Stephen Jones, Barbara (Jill) McCabe, Rashid Nayyar, Nancy Taylor, Jay Tyroler, Alice H. Pope, Madeline Erario (check if applicable) [v] There is more corporation information and Par. 1(b) is continued on a "Rezoning Attachment 1(b)" form. *** All listings which include partnerships, corporations, or trusts, to include the names of beneficiaries, must be broken down successively until: (a) only individual persons are listed or (b) the listing for a corporation having more than 10 shareholders has no shareholder owning 10% or more of any class of stock. In the case of an APPLICANT, TITLE OWNER, CONTRACT PURCHASER, or LESSEE*of the land that is a partnership, corporation, or trust, such successive breakdown must include a listing and further breakdown of all of its partners, of its shareholders as required above, and of beneficiaries of any trusts.
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