<html> <head> <title>Rule 20:06:13:0B Form for Reporting Medicare Supplement Policies.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:13:0B"> <META NAME="Description" Content="Administrative Rules 20:06:13:0B Form for Reporting Medicare Supplement Policies."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} @font-face {font-family:"Times Roman"; panose-1:0 0 0 0 0 0 0 0 0 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times","serif";} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><font size=3 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Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>FORM FOR REPORTING</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>MEDICARE SUPPLEMENT POLICIES</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Chapter 20:06:13</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>APPENDIX B</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>SEE: &#167;</span></font> <font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>20:06:13:53</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 18 SDR 225, effective July 17, 1992; 39 SDR 10, effective August 1, 2012.</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"; font-weight:bold'>APPENDIX B</span></font></b></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif";font-weight:bold'>&nbsp;</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"; font-weight:bold'>FORM FOR REPORTING</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"; font-weight:bold'>MEDICARE SUPPLEMENT POLICIES</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>Company Name:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ______________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>Address:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ______________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ______________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>Phone Number:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ______________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Due March 1, annually</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate.&nbsp; The information is to be grouped by individual policyholder.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;Policy and&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date of</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Certificate #&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Issuance</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=348 valign=top style='width:261.0pt;border:solid windowtext 1.0pt; padding:0in .05in 0in .05in'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'><br> <br> <br> </span></font></p> </td> <td width=286 valign=top style='width:214.2pt;border:solid windowtext 1.0pt; border-left:none;padding:0in .05in 0in .05in'> <p class=MsoNormal><font size=3 face="Times Roman"><span style='font-size: 12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=348 valign=top style='width:261.0pt;border:solid windowtext 1.0pt; border-top:none;padding:0in .05in 0in .05in'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'><br> <br> <br> </span></font></p> </td> <td width=286 valign=top style='width:214.2pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in .05in 0in .05in'> <p class=MsoNormal><font size=3 face="Times Roman"><span style='font-size: 12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=348 valign=top style='width:261.0pt;border:solid windowtext 1.0pt; border-top:none;padding:0in .05in 0in .05in'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'><br> <br> <br> </span></font></p> </td> <td width=286 valign=top style='width:214.2pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in .05in 0in .05in'> <p class=MsoNormal><font size=3 face="Times Roman"><span style='font-size: 12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=348 valign=top style='width:261.0pt;border:solid windowtext 1.0pt; border-top:none;padding:0in .05in 0in .05in'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'><br> <br> <br> </span></font></p> </td> <td width=286 valign=top style='width:214.2pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in .05in 0in .05in'> <p class=MsoNormal><font size=3 face="Times Roman"><span style='font-size: 12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Signature</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Name and Title (please type)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times Roman"><span style='font-size:12.0pt;font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times Roman"><span style='font-size:12.0pt; font-family:"Times Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></font></p> <p class=MsoNormal><font size=2 face=Times><span style='font-size:10.0pt'>&nbsp;</span></font></p> </div> </body> </html>