Fillable Part A and Authorization for Release of Information (ASA College)

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Part A and Authorization for Release of Information (ASA College)

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Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Page 1 of 9
GLC11646NY 7/17
Steps to le your claim:
• Part A and Authorization for Release of Information - To be completed by you.
• Part B - To be completed by your Health Care Provider.
• Part C - To be completed by your Employer.
Your completed claim should be submitted within (30) days after you become sick or disabled. In order to expedite your claim,
please have all portions completed in their entirety.
Completed Claim forms can be sent to:
Lincoln Life & Annuity Company of New York
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765
Fax: (877) 843-3950
disabilityclaims@lfg.com
NEW JERSEY TEMPORARY DISABILITY INSURANCE
Claimant Rights and Responsibilities
Rules for Filing a Claim and Appeal Rights
1. Itisyourresponsibilitytolethisclaimformpromptlyafteryoustopworkingduetoyourdisability.Benetsmaybedeniedor
reducediftheclaimisledlate.Ifyourclaimisledbeyondthethirtydayperiod,pleaseusethespaceprovidedonthe
reversesideofPartAtogiveyourreasonsforthelateling.
2. If you disagree with a determination on your claim and wish to appeal, you must do so in writing within ten days from the date
the decision was mailed. You do not need a lawyer at the appeal hearing.
Claimant Responsibilities:
1. Your signature certies that you understand any misrepresentation of fact or failure to disclose a material fact may be
punishableunderthelaw.ThisincludesanychangestotheMedicalCerticateortheEmployer’sStatementmadebyyou
without authorization by your physician or your employer.
2. You must inform us of any other payments you are receiving such as sick pay or wages, a pension from your last employer,
worker’scompensationbenets,SocialSecurityDisabilitybenets,ordisabilitybenetsfromyouremployerorunion.
3. Ifyoureceivearequestforcontinuedmedicalcertication(Form P30), you must have your physician complete and sign the
form. You should return it promptly.
4. Whenyourecoverorreturntowork,youmustreportthisdateimmediatelytotheDivisionofTemporaryDisabilityInsurance.
5. If you are requesting voluntary Federal Income Tax (F.I.T.)deductionstobewithheldfromyourdisabilitybenets,attachForm
W-4S(RequestforFederalIncomeTaxWithholdingFromSickPay) to your claim. Forms should be obtained from your employer or the
InternalRevenueService.
NEW YORK STAUTORY DISABILITY BENEFITS
Claimant: please read the following instructions carefully
1. Use this form if you become sick or disabled while employed or if you become sick or disabled within four (4) weeks after
termination of employment. Use claim form db-300 if you become sick or disabled after having been unemployed more than
four (4) weeks.
2. You must complete all items of part a - the "claimant's statement". Be accurate. Check all dates.
3. Be sure to date and sign your claim . If you cannot sign this claim form, your representative may sign it in your behalf. In that
event, the name, address and representative's relationship to you should be noted under the signature.
If you have any questions about claiming New York statutory
disabilitybenets,contactthenearestofceoftheNYSWorkers’
Compensation Board, or write to: Workers’ Compensation
Board, Disability Benets Bureau, 100 Broadway-Menands,
Albany, NY 12241-0005.
Sitienedudasrelacionadasconlareclamacióndebenecios,
porincapacidad,comuniqueseconlaocinamascercanade
laJuntadeCompensaciónObreradeNuevaYork,oescriba
a:Workers’CompensationBoard,DisabilityBenetsBureau,
100 Broadway-Menands, Albany, NY 12241-0005.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Page 2 of 9
GLC11646NY 7/17
StatutoryAndShortTermDisabilityClaimForm
PART A - CLAIMANT’S STATEMENT (Please Print or Type) Answer All Questions
1. Name (First/Middle/Last): ________________________________________________________________________________
2. SocialSecurityNumber: _________________________________________ 3. Age: ____________________________
4. Address: __________________________________________________________________________________________
City: _____________________________________________________ State: _______ Zip Code: _______________
Telephone Number: ________________________________________ Email Address: _________________________
5. DateofBirth: ____________________ 6. Married (Check One): h Yes h No 6a. Gender h Male h Female
7.
Reason for Inability to Work
(if injury, state how, when and where it occurred): h Illness h Accident h Pregnancy/Childbirth
_________________________________________________________________________________________________
_________________________________________________________________________________________________
8. DateUnabletoWork(Month/Day/Year): __________ 8a. I worked on that day: h Yes, number of hours ______ h No
I am (check one): h still employed h no longer employed – my last date of employment was: ____________________
Reason no longer employed: __________________________________________________________________________
8b. Ihavesinceworkedforwagesorprot: h Yes h No If Yes, when: ______________________________________
9. Provide the following information for all employers during the last 12 months.
Employer’s DateofEmployment Average Weekly Wages
Include Bonuses, Tips,
Commissions, Reasonable
Value of Board, Rent, etc.
Business Name Business Address Telephone Number
From
(Mo/Day/Yr)
Through
(Mo/Day/Yr)
10. Current Occupation (DescribeJob): _______________________________________________________________________
10a.Name of Union and Local Number, if member: ____________________________________________________________
I am insured by h The Union h My Employer
11. For the period of disability covered by this claim Yes No
a. Are you receiving wages, salary or separation pay: h h
b. Are you receiving or claiming:
i. Workers compensation for work connected disability h h
ii. UnemploymentInsuranceBenets h h
iii.Damagesforpersonalinjury h h
iv.BenetsundertheFederalSocialSecurityActforlongtermdisability h h
v.Anyotherdisabilitybenetsprovidedbyyouremployerorunion h h
vi.Pensionbenetsfromyourmostrecentemployer h h
vii.TemporaryDisabilityBenetsfromanotherstate h h
c. If “Yes” is checked in any of the items 11a or 11b, complete the following:
I have h received hclaimedbenetsfortheperiodDate: ______________ to Date: ________________________ .
Lincoln Life & Annuity Company of New York
PO Box 2609, Omaha, NE 68103-2609
Toll Free: (800) 423-2765 Fax: (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 3 of 9
GLC11646NY 7/17
12. Ihavereceiveddisabilitybenetsforanotherperiodorperiodsofdisabilitywithinthe52weeksimmediately
before my present disability began. h Yes h No
If“Yes”,llinthefollowing:Ihavebeenpaidby: ___________________________________________________________
fromDate: ______________________ to Date: ____________________ .
Certication and Signature Iwas unableto workduringtheperiod forwhich benetsare claimedand herebycertifythatI
havereadandunderstandmybenetrightsandresponsibilities.Iamawarethatifanyoftheforegoingstatementsmadebyme
are known to be false, or I knowingly fail to disclose a material fact, I may be subject to penalties, which may include criminal
prosecution.
Claimant’sSignature _______________________________________________ Date ____________________________
Phone Number: ____________________________ E-mail Address: _____________________________________________
If signed by other than claimant, print below: name, address, and relationship of representative:
Name: _______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: ________________________________________________________ State: _______ Zip Code: _______________
Relationship: __________________________________________________________________________________________
For Payment Method: Direct Deposit
FinancialInstitution’sname ______________________________________________________________________________
Type of Account h Checking h Savings
Bank Routing Number __________________________________________________________________________________
Account number _______________________________________________________________________________________
Information about income tax withholding
If your request for Short Term Disabilitybenetsisapproved,shouldLincolnLife&AnnuityCompanyofNewYorkwithhold
FederalIncometaxesfromyourbenetchecks?
h Yes hNoIfyes,howmuchshouldbewithheldfromeachcheck(minimumis$22.00perweek)?$_____________.00
Health Care Provider or Attending Physician must complete Part B on page 6.
Page 4 of 9
GLC11646NY 7/17
FRAUD NOTICES. For your protection, certain states require that the following notices appear on this form.
Alabama. Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenet
or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subjecttorestitutionnesorconnementinprison,oranycombinationthereof.
Alaska.Apersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveaninsurancecompanylesa
claim containing false, incomplete or misleading information may be prosecuted under state law.
Arizona. For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and
civil penalties.
Arkansas, Louisiana, Rhode Island and West Virginia. Any person who knowingly presents a false or
fraudulentclaimforpaymentofalossorbenetorknowinglypresentsfalseinformationinanapplicationfor
insuranceisguiltyofacrimeandmaybesubjecttonesandconnementinprison.
California. For your protection California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be
subjecttonesandconnementinstateprison.
Colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
includeimprisonment,nes,denialofinsuranceandcivildamages.Anyinsurancecompanyoragentof
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
DivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
Delaware.Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. It is a crime to provide false or misleading information to an insurer for the purpose of
defraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/ornes.Inaddition,aninsurer
maydenyinsurancebenetsiffalseinformationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
Florida.Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerlesastatementofclaim
or application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho.Anypersonwhoknowingly,andwithintenttodefraudordeceiveanyinsurancecompany,lesa
statement or claim containing any false, incomplete or misleading information is guilty of a felony.
Indiana.Apersonwhoknowinglyandwithintenttodefraudaninsurerlesastatementofclaimcontaining
any false, incomplete, or misleading information commits a felony.
Kentucky.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonles
a statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
thepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,nesoradenialofinsurancebenets
.
Maryland. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss
orbenetorknowinglyandwillfullypresentsfalseinformationinanapplicationforinsuranceisguiltyofa
crimeandmaybesubjecttonesandconnementinprison.
Minnesota.Apersonwholesaclaimwithintenttodefraudorhelpscommitafraudagainstaninsureris
guilty of a crime.
Page 5 of 9
GLC11646NY 7/17
New Hampshire.Anypersonwho,withapurposetoinjure,defraudordeceiveanyinsurancecompany,les
a statement of claim containing any false, incomplete or misleading information is subject to prosecution and
punishmentforinsurancefraud,asprovidedinRSA638:20.
New Jersey. Any person who knowingly les a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenet
or knowingly presents false information in an application for insurance is guilty of a crime and may be subject
tocivilnesandcriminalpenalties.
New York.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonles
an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act,whichisacrimeandsubjecttoacivilpenaltynottoexceedvethousanddollarsandthestatedvalue
of the claim for each such violation.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submitsanapplicationorlesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
Oklahoma. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon. Any person who knowingly and with intent to defraud any insurance company or other person: (1)
lesanapplicationfor insuranceorstatementof claimcontaininganymaterially falseinformation;or,(2)
conceals for the purpose of misleading, information concerning any material fact, may have committed a
fraudulent insurance act.
Pennsylvania. Any person who knowingly and with intent to defraud any insurance company or other
personlesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation
or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Puerto Rico. Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a
lossoranyotherbenet,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,
uponconviction,shallbesanctionedforeachviolationbyaneofnotlessthanvethousanddollars($5,000)and
notmorethantenthousanddollars($10,000),oraxedtermofimprisonmentforthree(3)years,orbothpenalties.
Shouldaggravatingcircumstancesbepresent,thepenaltythusestablishedmaybeincreasedtoamaximumof
ve(5)years,ifextenuatingcircumstancesarepresent,itmaybereducedtoaminimumoftwo(2)years
.
Tennessee, Virginia, and Washington. It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment,nesanddenialofinsurancebenets.
Texas. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of
acrimeandmaybesubjecttonesandconnementinstateprison.
FOR ALL OTHER STATES EXCLUDING CONNECTICUT AND KANSAS. A person may be committing
insurance fraud, if he or she submits an application or claim containing a false or deceptive statement with
intent to defraud (or knowing that he or she is helping to defraud) an insurance company.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Page 6 of 9
GLC11646NY 7/17
Authorization For Release Of Information
1. In connection with a claim for benets, I (the undersigned) authorize any physician, medical professional, pharmacist or
otherproviderofhealthcareservices,hospital,clinic,othermedicalormedicallyrelatedfacility;insuranceorreinsurancecompany;
government agency; department of labor; acquaintance; group policyholder; employer; or policy or benefit plan
administrator to release information from the records of:
Name of Insured: __________________________________________________________________________________
(Last) (First) (Middle)
DateofBirth: ______________________ SocialSecurityNumber: __________________________________________
2. Information to be released (hereinafter referred to as “My Information”):
• data or records regarding my medical history, treatment, prescriptions, consultations [including medical and psychological
reports, records, charts, notes (excluding psychotherapy notes),x-rays,lmsorcorrespondence,andanymedicalconditionI
 maynowhaveorhavehad];
• anyinformationregardinginsurancecoverage,claimsorbenets;and/or
• any information, data or records regarding my activities (including records relating to my Social Security, Workers’ Compensation,
retirementincome,nancialinformation,earningsandemploymenthistory).
3. Information to be released to: LincolnLife&AnnuityCompanyofNewYork(“Lincoln”)
PO Box 2609
Omaha, NE 68103-2609
4.
I understand My Information will be used by Lincoln to evaluate and administer my claim for benets. I also authorize
Lincoln to release My Information as follows:
• to its reinsurer, or other persons or organizations performing business or legal services in connection with my claim(s);or
• toavendor,approvedbyLincoln,whichspecializesintheapplicationforSocialSecurityDisabilityBenets
• tovendors/consultantsprovidingmewithwellness,disabilityorleaverelatedservicesaspartofanemployersponsoredbenetplan;or
• forself-insureddisabilityplansonly,tomyemployer;or
• for fully insured plans, I understand the the information obtained with this Authorization may be used in discussions
between Lincoln and my employer regarding my functional capacity, and any related restrictions and limitations, in order
tofacilitatemyreturntowork;or
• as otherwise may be required by law or as I may further authorize.
5.
I understand My Information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state
law. For Colorado claims, the disclosed information may not be re-disclosed or reused by the recipient under Colorado law.
6.
I understand that I may revoke this Authorization in writing at any time, except to the extent Lincoln has taken action in
reliance on this Authorization.To initiate revocation of this Authorization, direct all correspondence to Lincoln at the above
address. If written revocation is not received, this Authorization will be considered valid for a period of time not to exceed
24monthsfromthedateofmysignaturebelow,orthedurationofmyclaimforbenets,whicheverisshorter.
7. A photocopy of this Authorization is to be considered as valid as the original. I am entitled to receive a copy of this
Authorization.
SIGNATURE ________________________________________________________ DATE ___________________________
Claimant/legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/patient is a minor, legally incompetent,
or deceased.) Power of attorney or guardianship must be attached.
PRINT NAME: ________________________________________________________________________________________
Relationship to Claimant/Patient of personal/legal representative signing for Claimant/Patient __________________________
PHONE NO: __________________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________________
(Street)
____________________________________________________________________________________________________
(City) (State) (ZipCode)
LincolnLife&AnnuityCompanyofNewYork
ServiceOfce:POBox2609,Omaha,NE68103-2609
HomeOfce:Syracuse,NY
Toll free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
XXX-XX-
Page 7 of 9
GLC11646NY 7/17
PART B - HEALTH CARE PROVIDER’S STATEMENT (Please Print or Type)
1.Patient’sName(First/Middle/Last): __________________________________________________________________________
2.DateofBirth: ___________________
3.PrimaryDiagnosis/Analysis: __________________________________ DiagnosisCode: _________________________
SecondaryDiagnosis/Analysis: ________________________________ DiagnosisCode: _________________________
a.Patient’sSymptoms: ________________________________________________________________________________
b. Objective Findings: _________________________________________________________________________________
c. If inability to work is pregnancy related: Enter delivery date: ________ h Estimated h Actual
Type: h Vaginal hC-Section
4.PatientHospitalized? h Yes h No From: ______________________ To: _____________________________
5.SurgeryIndicated? h Yes h No a. Type: ____________________ b.Date: __________________________
Issurgeryforcosmeticpurposesonly?h Yes h No
List of Restrictions and Limitations: _______________________________________________________________________
Nature of treatment: __________________________________________________________________________________
6.EnterDatesfortheFollowing: Month Day Year
a.Dateofrsttreatmentforthisdisability _______________ ______ ________
b.Dateofmostrecenttreatmentforthisdisability _______________ ______ ________
c.Dateofnextofcevisitforthisdisability _______________ ______ ________
d.Datepatientwasunabletoworkbecauseofthisdisability _______________ ______ ________
e.Datepatientwillbeabletoperformusualwork(give approximate date) _______________ ______ ________
7. In your opinion, is this disability the result of injury arising out of and in the course of employment
oroccupationaldisease? h Yes h No
Remarks (Attached additional sheet , if necessary) _________________________________________________________________
Name
(s)
, address and specialty of other treating physicians:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
IafrmthatIama: h Chiropractor h Physician h Psychologist hDentist h Podiatrist h Nurse-Midwife
h Other: ___________________________________________________________________________
LicensedintheStateof: _____________________________ License Number: ___________________________________
________________________________________________________________ ___________________________
HealthCareProvider’sSignature Date
________________________________________________________________ ___________________________
HealthCareProvider’sName(PleasePrint) TelephoneNumber
OfceAddress: ________________________________________________________________________________________
City: ________________________________________________________ State: _______ Zip Code: _______________
E-mail Address: ___________________________________________________
Fax Number: _____________________________________________________
Page 8 of 9
GLC11646NY 7/17
PART C - EMPLOYER’S STATEMENT
1.Employee’sName: ___________________________________________________________________________________
2.Employee’sAddress: __________________________________________________________________________________
City: ______________________________________________________ State: _______ Zip Code: _______________
3.Employee’sOccupation: ______________________________________ SocialSecurityNumber: __________________
4.DateEmployed: ____________________________ EmployeeWorkState: _____________________________________
5.StatutoryDisabilityPolicyNumber_________________________ClaimLocationNumber:_________GroupID _______
EmployeeEffectiveDate ____________________
Indicate percentage Employer contributes to premium ____________% h Post Tax h Pre Tax
(If blank or not percentage we will tax at 100%)
6.ShortTermDisabilityPolicyNumber_______________________ClaimLocationNumber:_________GroupID ________
EmployeeEffectiveDate ____________________
Indicate percentage Employer contributes to premium ____________% h Post Tax h Pre Tax
(If blank or not a percentage we will tax at 100%)
7. Employee works: h Full time h Part time Number of Hours Per Week: _____________
Check usual days worked: h Mon h Tue h Wed h Thur h Fri hSat hSun
Is claimant an: h Employee h Owner h Partner h HighSchoolStudent Dateemployeelastworked: ___________
 Dateemployee’swageceased: _______________ Dateemployeereturnedtowork: _____________________________
 ForSTD,ifreturntoworkwasintermittent,listdatesworked: _________________________________________________
__________________________________________________________________________________________________
8.Arewagesbeingcontinuedduringdisability? h Yes h No If Yes h SalaryContinuance h SickPay h Vacation h PTO
BeginningDate: __________________ EndingDate: __________ Weekly Amount Paid: __________________________
IsreimbursementrequestedfortheStatutoryDisabilityBenet? h Yes h No
9.Dateyoureceivedthecompletedclaimform: _______________________________________________________________
Didthedisabilityoccurasaresultofemployment? h Yes h No
HasaWorker’sCompensationclaimbeenled? h Yes h No (If WC claim was denied include copy of denial notice.)
NameofyourWorker’sCompensationCarrier: _____________________________________________________________
Worker’sCompensationCarrierAddress: __________________________________________________________________
City: ________________________________________________ State: _______________ Zip Code: _____________
Doyouexpecttorehire? h Yes h No
IsemployeeamemberofaunionwhichprovidesN.Y.Statedisabilitybenets? h Yes h No
If employee is no longer in your employ, check reason: h LaborDispute h Lack of Work h Fired h Quit
Explain: ___________________________________________________________________________________________
HastheclaimantreceivedU.I.Benets? h Yes h No If Yes, give dates: ____________________________________
Page 9 of 9
GLC11646NY 7/17
Indicatebelowdatesand claimant’sGROSS earningsduringthelisted calenderweeks.For NYstatutory disabilitybenets,
please include the weekly value of board, lodging and tips.
Date Description of Calender Week Number of Days Worked Gross Wages
DisabilityBegan $
2
nd
WeekBeforeDisability $
3
rd
WeekBeforeDisability $
4
th
WeekBeforeDisability $
5
th
WeekBeforeDisability $
6
th
WeekBeforeDisability $
7
th
WeekBeforeDisability $
8
th
WeekBeforeDisability $
Total Gross Wages For Above Weeks $
For NEW JERSEY
StatutoryDisabilityBenetsONLY:
Base Weeks and Base Year Gross Wages
ABASEWEEKisacalenderweekinwhichtheclaimanthadNewJerseyearningsofatleasttheminimumNJTDBearnings
duringtheBaseyear.TheBASEYEARisthe52calenderweeksprecedingtheweekinwhichthedisabilityoccurred.
Total Number of Base Weeks: _______________________ Total Gross Wages in Base Year: _________________________
Employer Name: _______________________________________________________________________________________
Employer Address: _____________________________________________________________________________________
City: ________________________________________________________ State: _______ Zip Code: _______________
Name of person completing form: __________________________________________________________________________
Telephone Number: _________________________ E-mail Address: _____________________________________________
________________________________________________________________ ___________________________
Signature Date
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Completed 26 July 2020

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