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Tc /F3 11.0 Tf 1 0 0 1 70.92 469.08 Tm <504C4541534520> Tj /F3 12.0 Tf 1 0 0 1 117.36 469.44 Tm <414E5357455220> Tj /F3 13.0 Tf 1 0 0 1 174.96 469.80 Tm <54484520> Tj /F3 12.5 Tf 1 0 0 1 205.20 470.16 Tm <464F4C4C6757494E4728434952434C4520> Tj /F3 12.0 Tf 1 0 0 1 334.08 470.52 Tm <4F4E4529> Tj /F3 9.0 Tf 1 0 0 1 70.92 455.04 Tm <57617320> Tj /F3 8.5 Tf 1 0 0 1 92.16 455.40 Tm <616E20> Tj /F3 10.0 Tf 1 0 0 1 104.76 453.96 Tm <224170706C69636174696F6E20> Tj /F3 10.5 Tf 1 0 0 1 161.64 455.76 Tm <666F7220> Tj /F3 9.5 Tf 1 0 0 1 177.84 455.76 Tm <42656E65666674732220> Tj /F3 10.0 Tf 1 0 0 1 220.32 456.12 Tm <666F726D20> Tj 1 0 0 1 244.44 456.12 Tm <66726F6D20> Tj 1 0 0 1 268.20 455.76 Tm <796F757220> Tj /F3 9.0 Tf 1 0 0 1 291.24 456.48 Tm <696E737572616E636520> Tj /F3 10.0 Tf 1 0 0 1 335.16 456.48 Tm <6361727269657220> Tj /F3 15.0 Tf 1 0 0 1 367.20 456.48 Tm <66696C65643F20> Tj /F3 8.5 Tf 1 0 0 1 423.00 456.48 Tm <596573> Tj /F3 9.5 Tf 1 0 0 1 71.28 441.72 Tm <286C6620> Tj 1 0 0 1 82.44 441.72 Tm <74686520> Tj /F3 8.5 Tf 1 0 0 1 99.00 442.08 Tm <61626F766520> Tj /F3 8.0 Tf 1 0 0 1 126.36 442.08 Tm <68617320> Tj /F3 10.0 Tf 1 0 0 1 142.20 442.08 Tm <6E6F7420> Tj /F3 9.5 Tf 1 0 0 1 159.48 442.44 Tm <6265656E20> Tj 1 0 0 1 183.96 442.44 Tm <646F6E652C20> Tj /F3 10.0 Tf 1 0 0 1 211.68 442.08 Tm <796F757220> Tj /F3 9.5 Tf 1 0 0 1 234.72 442.80 Tm <6D65646963616C20> Tj /F3 9.0 Tf 1 0 0 1 270.72 442.80 Tm <657870656E73657320> Tj /F3 11.0 Tf 1 0 0 1 312.48 443.16 Tm <77696C6C20> Tj /F3 10.0 Tf 1 0 0 1 331.56 443.16 Tm <6E6F7420> Tj /F3 9.0 Tf 1 0 0 1 348.84 443.16 Tm <626520> Tj /F3 9.5 Tf 1 0 0 1 362.16 443.16 Tm <7265636F676E697A656420> Tj /F3 10.0 Tf 1 0 0 1 412.56 443.16 Tm <666F7220> Tj /F3 9.5 Tf 1 0 0 1 427.68 442.80 Tm <7061796D656E742E> Tj /F3 9.0 Tf 1 0 0 1 71.28 428.04 Tm <536174697366616374696F6E20> Tj /F3 10.5 Tf 1 0 0 1 121.68 428.76 Tm <6F66796F757220> Tj /F3 9.5 Tf 1 0 0 1 155.16 428.76 Tm <6163636F756E7420> Tj /F3 10.0 Tf 1 0 0 1 192.96 429.12 Tm <776F756C6420> Tj /F3 9.5 Tf 1 0 0 1 222.84 429.12 Tm <7468656E20> Tj /F3 9.0 Tf 1 0 0 1 244.80 429.48 Tm <6265636F6D6520> Tj /F3 10.5 Tf 1 0 0 1 281.52 429.12 Tm <796F756C20> Tj /F3 10.0 Tf 1 0 0 1 304.20 429.48 Tm <64697265637420> Tj 1 0 0 1 332.28 429.84 Tm <726573706F6E736962696C6974792E29> Tj 0.00 Tc /F3 10.5 Tf 1 0 0 1 480.24 455.76 Tm <4E6F> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 71.64 388.08 Tm <506F6C69637920> Tj /F3 10.0 Tf 1 0 0 1 100.08 388.80 Tm <486F6C64657220> Tj 1 0 0 1 132.84 388.80 Tm <4E> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 71.64 368.28 Tm <506F6C69637920> Tj 1 0 0 1 100.08 368.64 Tm <486F6C646572277320> Tj 1 0 0 1 138.96 368.64 Tm <41646472657373> Tj /F3 15.0 Tf 1 0 0 1 216.36 349.20 Tm <2873726565742920> Tj 1 0 0 1 361.08 349.92 Tm <28636974796C73746174652920> Tj /F3 9.5 Tf 1 0 0 1 448.92 349.56 Tm <287A697020> Tj 1 0 0 1 468.00 348.48 Tm <636F646529> Tj /F3 9.0 Tf 1 0 0 1 72.36 328.32 Tm <506F6C69637920> Tj /F3 15.0 Tf 1 0 0 1 100.08 328.68 Tm <4E756D6265724A6E737572616E636520> Tj /F3 9.5 Tf 1 0 0 1 333.00 329.40 Tm <46696C6520> Tj /F3 12.5 Tf 1 0 0 1 352.08 329.40 Tm <2320> Tj /F3 15.0 Tf 1 0 0 1 363.24 329.76 Tm <28696C6C6E6F766D295F2D2D2E5F2D> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 72.36 308.16 Tm <496E737572616E636520> Tj /F3 10.0 Tf 1 0 0 1 115.20 308.52 Tm <4361727269657220> Tj /F3 9.5 Tf 1 0 0 1 149.40 308.88 Tm <4E616D65> Tj 0.00 Tc 1 0 0 1 72.36 288.00 Tm <4164647265> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 305.64 268.56 Tm <286369747920> Tj 1 0 0 1 325.80 268.20 Tm <2F20> Tj 1 0 0 1 331.20 268.20 Tm <737461746529> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 445.32 267.84 Tm <287A697020> Tj 1 0 0 1 464.04 267.12 Tm <636F646529> Tj 0.00 Tc 1 0 0 1 72.72 227.16 Tm <436C61696D20> Tj /F3 15.0 Tf 1 0 0 1 100.44 227.52 Tm <526570726573656E74617469766520> Tj /F3 9.5 Tf 1 0 0 1 323.28 227.52 Tm <496E737572616E636520> Tj /F3 10.0 Tf 1 0 0 1 368.64 227.52 Tm <50686F6E6523> Tj 0.00 Tc /F3 11.0 Tf 1 0 0 1 156.24 193.68 Tm <494E535552414E434520> Tj /F3 11.5 Tf 1 0 0 1 224.64 193.68 Tm <415554484F52495A4154494F4E20> Tj 1 0 0 1 324.36 193.68 Tm <414E4420> Tj /F3 10.5 Tf 1 0 0 1 352.44 193.68 Tm <41535349474E4D454E54> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 73.08 180.00 Tm <4920> Tj /F3 9.0 Tf 1 0 0 1 78.12 180.00 Tm <68657265627920> Tj /F3 9.5 Tf 1 0 0 1 109.80 180.00 Tm <617574686F72697A65> Tj 0.00 Tc /F3 10.0 Tf 1 0 0 1 326.52 180.00 Tm <746F20> Tj /F3 9.5 Tf 1 0 0 1 338.40 180.00 Tm <6675726E69736820> Tj /F3 10.0 Tf 1 0 0 1 371.52 179.64 Tm <696E666F726D6174696F6E20> Tj 1 0 0 1 426.24 179.64 Tm <746F20> Tj /F3 9.0 Tf 1 0 0 1 437.76 179.28 Tm <696E737572616E6365> Tj 0.00 Tc 1 0 0 1 73.08 165.96 Tm <636172726965727320> Tj /F3 9.5 Tf 1 0 0 1 106.92 166.32 Tm <636F6E6365726E696E6720> Tj /F3 10.0 Tf 1 0 0 1 158.76 165.96 Tm <6D7920> Tj /F3 9.5 Tf 1 0 0 1 175.68 166.32 Tm <696C6C6E65737320> Tj /F3 9.0 Tf 1 0 0 1 205.92 166.32 Tm <616E6420> Tj /F3 10.0 Tf 1 0 0 1 223.92 166.32 Tm <74726561746D656E74732C20> Tj /F3 9.0 Tf 1 0 0 1 277.20 166.32 Tm <616E6420> Tj 1 0 0 1 295.56 166.32 Tm <4920> Tj /F3 9.5 Tf 1 0 0 1 300.96 166.32 Tm <68657265627920> Tj /F3 8.5 Tf 1 0 0 1 333.72 165.96 Tm <61737369676E20> Tj /F3 10.0 Tf 1 0 0 1 362.16 165.96 Tm <746F20> Tj /F3 9.5 Tf 1 0 0 1 374.04 165.96 Tm <74686520> Tj /F3 9.0 Tf 1 0 0 1 390.60 165.60 Tm <70687973696369616E20> Tj /F3 9.5 Tf 1 0 0 1 432.72 165.60 Tm <616C6C20> Tj /F3 9.0 Tf 1 0 0 1 445.32 164.88 Tm <7061796D656E747320> Tj /F3 11.0 Tf 1 0 0 1 488.52 164.16 Tm <666F72> Tj /F3 9.0 Tf 1 0 0 1 73.08 152.64 Tm <6D65646963616C20> Tj 1 0 0 1 108.36 153.00 Tm <736572766963657320> Tj /F3 10.0 Tf 1 0 0 1 145.08 153.00 Tm <72656E646572656420> Tj /F3 10.5 Tf 1 0 0 1 189.00 152.64 Tm <746F20> Tj /F3 9.5 Tf 1 0 0 1 201.24 152.64 Tm <6D7973656C6620> Tj /F3 10.0 Tf 1 0 0 1 232.56 152.64 Tm <6F7220> Tj 1 0 0 1 244.80 152.64 Tm <6D7920> Tj /F3 10.5 Tf 1 0 0 1 261.36 152.64 Tm <646570656E64656E732E20> Tj /F3 9.5 Tf 1 0 0 1 319.68 152.64 Tm <4920> Tj 1 0 0 1 325.44 152.28 Tm <756E6465727374616E6420> Tj 1 0 0 1 377.64 152.28 Tm <7468617420> Tj 1 0 0 1 397.08 152.28 Tm <4920> Tj /F3 9.0 Tf 1 0 0 1 402.84 152.28 Tm <616D20> Tj 1 0 0 1 418.68 152.28 Tm <726573706F6E7369626C6520> Tj /F3 10.0 Tf 1 0 0 1 469.44 150.84 Tm <666F7220> Tj /F3 9.0 Tf 1 0 0 1 484.56 150.48 Tm <616E79> Tj 1 0 0 1 73.08 138.96 Tm <616D6F756E7420> Tj /F3 10.5 Tf 1 0 0 1 107.64 139.32 Tm <6E6F7420> Tj /F3 9.5 Tf 1 0 0 1 125.64 138.96 Tm <636F766572656420> Tj 1 0 0 1 163.44 138.96 Tm <627920> Tj 1 0 0 1 177.12 138.96 Tm <696E737572616E63652E> Tj 0.00 Tc 1 0 0 1 73.44 112.32 Tm <5369726E6174757265> Tj 0.00 Tc /F3 10.5 Tf 1 0 0 1 143.28 268.20 Tm <28702E6F2E20> Tj 1 0 0 1 168.12 268.20 Tm <626F7820> Tj /F3 10.0 Tf 1 0 0 1 188.64 268.20 Tm <6F7220> Tj /F3 9.5 Tf 1 0 0 1 200.88 268.20 Tm <73747265657429> Tj ET endstream endobj 6 0 obj << /Type /Font /Subtype /Type1 /BaseFont /Helvetica /Encoding /WinAnsiEncoding >> endobj 7 0 obj << /Length 8 0 R >> stream North Fork Orthopaedic & Sports Medicine P.L.L.C.Patient Registration Form - No-Fault Claims Patient's Name te of Birth-Sex SS# Marital Referring Physician--Date of Accident-Time-Home Ad&ess Ciw/State Zip Emergency Con relationship) PLEASE ANSWER THE FOLLgWING(CIRCLE ONE)Was an "Application for Beneffts" form from your insurance carrier filed? Yes(lf the above has not been done, your medical expenses will not be recognized for payment.Satisfaction ofyour account would then become youl direct responsibility.) No Policy Holder N Policy Holder's Address(sreet) (citylstate) (zip code)Policy NumberJnsurance File # (illnovm)_--._- Insurance Carrier Name Addre (city / state) (zip code) Claim Representative Insurance Phone# INSURANCE AUTHORIZATION AND ASSIGNMENT I hereby authorize to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to the physician all payments formedical services rendered to myself or my dependens. I understand that I am responsible for anyamount not covered by insurance. 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>((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( endstream endobj 13 0 obj << /Length 22398 >> stream BT 3 Tr 0.00 Tc /F3 9.0 Tf 1 0 0 1 49.68 730.44 Tm <47726F757023> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 142.20 730.08 Tm <50617469656E7420> Tj 1 0 0 1 172.08 730.08 Tm <4E616D653A> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 317.88 730.08 Tm <4D5223> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 435.60 730.44 Tm <446174653A> Tj 0.00 Tc /F3 11.0 Tf 1 0 0 1 155.52 695.16 Tm <4E455720> Tj 1 0 0 1 184.68 695.16 Tm <594F52492820> Tj 1 0 0 1 219.96 695.16 Tm <4D4F544F5220> Tj /F3 11.5 Tf 1 0 0 1 264.60 695.16 Tm <56454849434C4520> Tj 1 0 0 1 318.24 695.16 Tm <4E4F2D4641495D4C5420> Tj /F3 10.5 Tf 1 0 0 1 378.00 695.16 Tm <494E53494A52414E434520> Tj /F3 11.5 Tf 1 0 0 1 446.04 695.16 Tm <4C4157> Tj /F3 10.5 Tf 1 0 0 1 221.76 682.56 Tm <41535349474E4D454E5420> Tj 1 0 0 1 297.72 682.56 Tm <4F4620> Tj 1 0 0 1 315.72 682.56 Tm <42454E454649545320> Tj /F3 11.0 Tf 1 0 0 1 372.24 682.92 Tm <464F524D> Tj 0.00 Tc 1 0 0 1 48.60 633.60 Tm <492C> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 181.08 658.44 Tm <28464F5220> Tj /F3 10.0 Tf 1 0 0 1 208.44 658.08 Tm <4143434944454E545320> Tj /F3 10.5 Tf 1 0 0 1 272.16 658.08 Tm <4F4343494952494E4720> Tj /F3 9.5 Tf 1 0 0 1 332.64 658.08 Tm <4F4E20> Tj /F3 10.5 Tf 1 0 0 1 350.64 658.08 Tm <414E4420> Tj 1 0 0 1 376.92 658.08 Tm <414654455220> Tj /F3 10.0 Tf 1 0 0 1 414.72 658.08 Tm <332F312F303229> Tj /F3 12.0 Tf 1 0 0 1 172.80 633.60 Tm <282241737369706F72272920> Tj /F3 9.0 Tf 1 0 0 1 231.84 633.24 Tm <68657265627920> Tj 1 0 0 1 263.88 633.24 Tm <61737369676E20> Tj /F3 16.5 Tf 1 0 0 1 294.12 633.24 Tm <746F20> Tj /F3 9.0 Tf 1 0 0 1 343.80 633.60 Tm <2853656520> Tj /F3 16.5 Tf 1 0 0 1 365.76 634.32 Tm <52656C6F772920> Tj /F3 9.0 Tf 1 0 0 1 434.16 631.44 Tm <2C20> Tj /F3 10.0 Tf 1 0 0 1 439.56 633.60 Tm <282241737369676E6565222920> Tj 1 0 0 1 500.04 632.88 Tm <616C6C20> Tj 1 0 0 1 513.72 632.88 Tm <7269676874732C> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 73.44 623.16 Tm <285072687420> Tj /F3 8.0 Tf 1 0 0 1 95.76 623.16 Tm <70617469656E74277320> Tj /F3 13.5 Tf 1 0 0 1 128.88 622.44 Tm <6D6D652920> Tj /F3 8.0 Tf 1 0 0 1 299.16 622.80 Tm <285072696E7420> Tj 1 0 0 1 321.84 622.44 Tm <686F73706974616C20> Tj 1 0 0 1 352.08 622.44 Tm <6F7220> Tj 1 0 0 1 361.80 622.44 Tm <6865616C746820> Tj /F3 7.5 Tf 1 0 0 1 386.28 622.44 Tm <6361726520> Tj /F3 8.0 Tf 1 0 0 1 403.56 622.80 Tm <70726F796964657220> Tj /F3 7.0 Tf 1 0 0 1 435.96 622.44 Tm <6E6172446529> Tj /F3 10.0 Tf 1 0 0 1 48.60 610.92 Tm <70726976696C656765732C20> Tj /F3 9.0 Tf 1 0 0 1 97.20 610.20 Tm <616E6420> Tj /F3 9.5 Tf 1 0 0 1 115.56 610.20 Tm <72656D656469657320> Tj /F3 10.0 Tf 1 0 0 1 157.68 610.20 Tm <746F20> Tj /F3 9.5 Tf 1 0 0 1 169.20 610.92 Tm <7061796D656E7420> Tj /F3 10.0 Tf 1 0 0 1 209.88 610.20 Tm <666F7220> Tj /F3 9.5 Tf 1 0 0 1 225.00 610.20 Tm <6865616C746820> Tj /F3 9.0 Tf 1 0 0 1 254.16 610.20 Tm <6361726520> Tj /F3 9.5 Tf 1 0 0 1 275.04 610.20 Tm <736572766963657320> Tj 1 0 0 1 313.20 610.92 Tm <70726F766964656420> Tj 1 0 0 1 354.60 610.20 Tm <627920> Tj /F3 9.0 Tf 1 0 0 1 368.28 610.20 Tm <61737369676E656520> Tj /F3 10.0 Tf 1 0 0 1 408.24 610.20 Tm <746F20> Tj 1 0 0 1 419.76 610.20 Tm <776869636820> Tj /F3 11.0 Tf 1 0 0 1 449.28 610.20 Tm <4920> Tj /F3 9.0 Tf 1 0 0 1 455.76 610.20 Tm <616D20> Tj /F3 10.0 Tf 1 0 0 1 471.96 610.20 Tm <656E7469746C656420> Tj /F3 9.5 Tf 1 0 0 1 508.32 609.84 Tm <756E64657220> Tj /F3 10.5 Tf 1 0 0 1 536.04 609.84 Tm <41727469636C65> Tj /F3 6.5 Tf 1 0 0 1 48.96 597.60 Tm <3520> Tj /F3 12.0 Tf 1 0 0 1 55.08 597.60 Tm <4920> Tj /F3 9.0 Tf 1 0 0 1 62.28 597.96 Tm <2874686520> Tj /F3 10.0 Tf 1 0 0 1 81.36 597.60 Tm <4E6F2D4661756C7420> Tj /F3 9.5 Tf 1 0 0 1 124.20 597.24 Tm <737461747574652920> Tj /F3 10.0 Tf 1 0 0 1 159.12 597.60 Tm <6F6620> Tj /F3 9.0 Tf 1 0 0 1 171.00 597.60 Tm <74686520> Tj /F3 9.5 Tf 1 0 0 1 187.20 597.60 Tm <496E737572616E636520> Tj /F3 10.0 Tf 1 0 0 1 232.20 597.60 Tm <4C61772E> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 48.60 572.40 Tm <54686520> Tj 1 0 0 1 68.04 572.40 Tm <41737369676E656520> Tj 1 0 0 1 110.52 572.04 Tm <68657265627920> Tj /F3 10.0 Tf 1 0 0 1 143.28 572.40 Tm <63657274696669657320> Tj /F3 9.5 Tf 1 0 0 1 181.44 572.40 Tm <7468617420> Tj 1 0 0 1 200.52 572.40 Tm <7468657920> Tj /F3 9.0 Tf 1 0 0 1 222.12 572.40 Tm <6861766520> Tj /F3 9.5 Tf 1 0 0 1 245.16 572.40 Tm <6E6F7420> Tj 1 0 0 1 261.72 572.40 Tm <726563656976656420> Tj 1 0 0 1 302.04 572.40 Tm <616E7920> Tj 1 0 0 1 320.40 573.12 Tm <7061796D656E7420> Tj /F3 10.0 Tf 1 0 0 1 360.72 572.40 Tm <66726F6D20> Tj 1 0 0 1 384.84 572.40 Tm <6F7220> Tj /F3 9.0 Tf 1 0 0 1 397.08 572.40 Tm <6F6E20> Tj /F3 11.0 Tf 1 0 0 1 410.40 572.40 Tm <626568616C666F6674686520> Tj /F3 10.0 Tf 1 0 0 1 468.36 572.04 Tm <41737369676E6F7220> Tj /F3 9.0 Tf 1 0 0 1 511.92 572.04 Tm <616E6420> Tj /F3 9.5 Tf 1 0 0 1 530.64 572.04 Tm <7368616C6C20> Tj /F3 10.0 Tf 1 0 0 1 554.04 572.04 Tm <6E6F74> Tj /F3 9.0 Tf 1 0 0 1 48.24 560.16 Tm <70757273756520> Tj /F3 9.5 Tf 1 0 0 1 80.28 560.16 Tm <7061796D656E7420> Tj /F3 10.0 Tf 1 0 0 1 120.60 559.44 Tm <6469726563746C7920> Tj 1 0 0 1 156.96 559.44 Tm <66726F6D20> Tj /F3 9.0 Tf 1 0 0 1 180.72 559.80 Tm <74686520> Tj /F3 10.0 Tf 1 0 0 1 196.92 559.80 Tm <41737369676E6F7220> Tj 1 0 0 1 239.40 559.80 Tm <666F7220> Tj /F3 9.0 Tf 1 0 0 1 254.52 559.80 Tm <736572766963657320> Tj /F3 10.0 Tf 1 0 0 1 292.32 560.52 Tm <70726F766964656420> Tj 1 0 0 1 334.08 559.80 Tm <627920> Tj /F3 9.0 Tf 1 0 0 1 348.12 559.80 Tm <7361696420> Tj /F3 9.5 Tf 1 0 0 1 367.92 559.80 Tm <41737369676E656520> Tj /F3 10.0 Tf 1 0 0 1 411.48 559.80 Tm <666F7220> Tj 1 0 0 1 426.96 559.80 Tm <696E6A757269657320> Tj /F3 9.5 Tf 1 0 0 1 462.24 559.80 Tm <7375737461696E656420> Tj /F3 9.0 Tf 1 0 0 1 506.52 559.44 Tm <64756520> Tj /F3 9.5 Tf 1 0 0 1 525.24 559.44 Tm <746F20> Tj 1 0 0 1 536.40 559.80 Tm <74686520> Tj /F3 10.0 Tf 1 0 0 1 552.96 559.44 Tm <6D6F746F72> Tj 0.00 Tc 1 0 0 1 48.24 547.20 Tm <76656869636C6520> Tj /F3 9.5 Tf 1 0 0 1 82.80 547.20 Tm <6163636964656E7420> Tj /F3 10.0 Tf 1 0 0 1 121.68 547.20 Tm <776869636820> Tj /F3 9.5 Tf 1 0 0 1 151.20 547.20 Tm <6F6363757272656420> Tj 1 0 0 1 192.60 547.20 Tm <6F6E> Tj 0.00 Tc 1 0 0 1 48.24 534.24 Tm <6E6F7420> Tj /F3 10.0 Tf 1 0 0 1 64.80 534.24 Tm <776974687374616E64696E6720> Tj /F3 9.5 Tf 1 0 0 1 124.20 534.60 Tm <616E7920> Tj /F3 10.0 Tf 1 0 0 1 142.56 534.96 Tm <7072696F7220> Tj 1 0 0 1 166.68 534.60 Tm <7772697474656E20> Tj /F3 9.0 Tf 1 0 0 1 200.52 534.60 Tm <61677265656D656E7420> Tj 1 0 0 1 248.40 534.60 Tm <746F20> Tj 1 0 0 1 259.20 534.60 Tm <74686520> Tj /F3 15.0 Tf 1 0 0 1 275.40 534.60 Tm <636F6E74756172792E20> Tj /F3 8.0 Tf 1 0 0 1 351.00 535.32 Tm <285072696E7420> Tj 1 0 0 1 373.68 534.60 Tm <6163636964656E7420> Tj /F3 7.5 Tf 1 0 0 1 406.08 534.60 Tm <6461746529> Tj /F3 9.5 Tf 1 0 0 1 48.24 511.20 Tm <5468697320> Tj /F3 9.0 Tf 1 0 0 1 70.20 511.56 Tm <61677265656D656E7420> Tj /F3 9.5 Tf 1 0 0 1 118.44 511.56 Tm <6D617920> Tj /F3 9.0 Tf 1 0 0 1 140.04 511.56 Tm <626520> Tj /F3 9.5 Tf 1 0 0 1 153.00 511.56 Tm <7265766F6B656420> Tj 1 0 0 1 191.52 511.56 Tm <627920> Tj 1 0 0 1 204.84 511.56 Tm <74686520> Tj /F3 9.0 Tf 1 0 0 1 221.40 511.56 Tm <61737369676E656520> Tj /F3 9.5 Tf 1 0 0 1 260.64 511.56 Tm <7768656E20> Tj 1 0 0 1 286.92 511.56 Tm <62656E656669747320> Tj /F3 9.0 Tf 1 0 0 1 324.72 511.92 Tm <61726520> Tj /F3 9.5 Tf 1 0 0 1 340.92 511.92 Tm <6E6F7420> Tj 1 0 0 1 357.48 512.28 Tm <70617961626C6520> Tj /F3 9.0 Tf 1 0 0 1 394.20 511.56 Tm <626173656420> Tj /F3 9.5 Tf 1 0 0 1 422.28 511.92 Tm <75706F6E20> Tj /F3 9.0 Tf 1 0 0 1 446.76 511.92 Tm <74686520> Tj /F3 10.0 Tf 1 0 0 1 462.60 511.92 Tm <61737369676E6F72277320> Tj /F3 9.5 Tf 1 0 0 1 510.84 511.56 Tm <6C61636B20> Tj /F3 12.5 Tf 1 0 0 1 531.72 511.56 Tm <6F66> Tj /F3 9.0 Tf 1 0 0 1 48.24 498.96 Tm <636F76657261676520> Tj /F3 9.5 Tf 1 0 0 1 90.00 498.96 Tm <616E642F6F7220> Tj /F3 10.5 Tf 1 0 0 1 120.60 498.96 Tm <76696F6C6174696F6E20> Tj /F3 11.0 Tf 1 0 0 1 163.08 498.96 Tm <6F666120> Tj /F3 10.5 Tf 1 0 0 1 182.16 499.68 Tm <706F6C69637920> Tj /F3 10.0 Tf 1 0 0 1 212.40 498.96 Tm <636F6E646974696F6E20> Tj /F3 9.0 Tf 1 0 0 1 255.96 499.32 Tm <64756520> Tj /F3 10.0 Tf 1 0 0 1 273.96 499.32 Tm <746F20> Tj /F3 9.5 Tf 1 0 0 1 285.48 499.32 Tm <74686520> Tj 1 0 0 1 302.04 499.32 Tm <616374696F6E7320> Tj 1 0 0 1 335.88 499.32 Tm <6F7220> Tj 1 0 0 1 347.76 499.32 Tm <636F6E6475637420> Tj /F3 11.0 Tf 1 0 0 1 384.84 499.32 Tm <6F6674686520> Tj /F3 9.0 Tf 1 0 0 1 413.28 499.32 Tm <61737369676E6F722E> Tj 0.00 Tc /F3 10.5 Tf 1 0 0 1 47.88 474.84 Tm <417D495920> Tj /F3 8.5 Tf 1 0 0 1 72.00 474.84 Tm <504552534F4E20> Tj /F3 9.5 Tf 1 0 0 1 112.68 474.84 Tm <57484F20> Tj /F3 10.5 Tf 1 0 0 1 138.96 474.84 Tm <4B4E4F4D4E474C5920> Tj /F3 9.5 Tf 1 0 0 1 203.40 475.20 Tm <414E4420> Tj /F3 10.0 Tf 1 0 0 1 227.52 475.20 Tm <574954494920> Tj /F3 9.5 Tf 1 0 0 1 255.60 475.20 Tm <494E54454E5420> Tj /F3 9.0 Tf 1 0 0 1 294.12 475.20 Tm <544F20> Tj /F3 9.5 Tf 1 0 0 1 309.60 475.20 Tm <4445465241554420> Tj 1 0 0 1 358.92 475.20 Tm <41492E7B5920> Tj 1 0 0 1 383.40 475.20 Tm <494E53542752414E434520> Tj 1 0 0 1 443.16 475.20 Tm <434F4D50414E5920> Tj /F3 9.0 Tf 1 0 0 1 495.36 474.84 Tm <4F5220> Tj /F3 9.5 Tf 1 0 0 1 511.92 474.84 Tm <4F54484552> Tj /F3 8.5 Tf 1 0 0 1 48.24 463.32 Tm <504552534F4E20> Tj /F3 9.0 Tf 1 0 0 1 88.20 463.68 Tm <46494C455320> Tj /F3 9.5 Tf 1 0 0 1 117.36 463.32 Tm <414E20> Tj 1 0 0 1 134.28 463.68 Tm <4150504C49434154494F4E20> Tj /F3 9.0 Tf 1 0 0 1 202.32 463.68 Tm <464F5220> Tj /F3 9.5 Tf 1 0 0 1 224.28 463.68 Tm <434F4D4D45524349414C20> Tj 1 0 0 1 294.12 463.68 Tm <494E535552414E434520> Tj /F3 8.5 Tf 1 0 0 1 353.52 463.68 Tm <4F5220> Tj /F3 10.5 Tf 1 0 0 1 369.36 464.04 Tm <4120> Tj /F3 9.5 Tf 1 0 0 1 379.80 463.68 Tm <53544154454D454E5420> Tj /F3 8.5 Tf 1 0 0 1 441.36 463.68 Tm <4F4620> Tj /F3 10.0 Tf 1 0 0 1 456.48 463.68 Tm <434C41494D20> Tj /F3 9.0 Tf 1 0 0 1 491.04 463.68 Tm <464F5220> Tj /F3 10.5 Tf 1 0 0 1 513.36 463.68 Tm <414E59> Tj /F3 9.5 Tf 1 0 0 1 48.24 451.80 Tm <434F4D4D45524349414C20> Tj /F3 9.0 Tf 1 0 0 1 117.72 452.16 Tm <4F5220> Tj 1 0 0 1 134.28 452.16 Tm <504552534F4E414C20> Tj 1 0 0 1 188.64 452.16 Tm <494E535427502E414E434520> Tj 1 0 0 1 247.32 452.16 Tm <42454E454649545320> Tj /F3 9.5 Tf 1 0 0 1 296.64 452.16 Tm <434F4E5441494E494E4720> Tj /F3 10.0 Tf 1 0 0 1 361.08 452.52 Tm <414E5920> Tj 1 0 0 1 385.20 452.52 Tm <4D4154455249414C4C5920> Tj 1 0 0 1 452.52 452.52 Tm <464149534520> Tj /F3 9.5 Tf 1 0 0 1 486.00 452.16 Tm <494E464F524D4154494F4E2C20> Tj /F3 9.0 Tf 1 0 0 1 560.88 452.16 Tm <4F52> Tj 1 0 0 1 48.24 440.64 Tm <434F4E4345414C5320> Tj 1 0 0 1 102.60 441.00 Tm <464F5220> Tj 1 0 0 1 124.92 440.64 Tm <54484520> Tj /F3 8.5 Tf 1 0 0 1 146.52 440.64 Tm <50542C52504F534520> Tj 1 0 0 1 192.96 441.00 Tm <4F4620> Tj /F3 9.5 Tf 1 0 0 1 208.08 441.00 Tm <4D49534C454144494E472C20> Tj 1 0 0 1 274.32 441.00 Tm <494E464F524D4154494F4E20> Tj 1 0 0 1 347.04 441.00 Tm <434F4E4345524E494E4320> Tj /F3 7.5 Tf 1 0 0 1 414.72 441.00 Tm <412E492E545920> Tj /F3 9.0 Tf 1 0 0 1 438.84 441.00 Tm <4641435420> Tj /F3 10.0 Tf 1 0 0 1 466.56 441.00 Tm <4D4154455249414C20> Tj /F3 9.0 Tf 1 0 0 1 521.28 441.00 Tm <5448455245544F2C> Tj /F3 9.5 Tf 1 0 0 1 47.88 429.12 Tm <414E4420> Tj /F3 10.0 Tf 1 0 0 1 71.64 429.48 Tm <414E5920> Tj /F3 9.0 Tf 1 0 0 1 95.76 429.48 Tm <504552534F4E20> Tj 1 0 0 1 136.80 429.48 Tm <57484F2C20> Tj /F3 10.0 Tf 1 0 0 1 165.24 429.48 Tm <494E20> Tj /F3 9.5 Tf 1 0 0 1 178.56 429.48 Tm <434F4E4E454354494F4E20> Tj 1 0 0 1 245.52 429.48 Tm <5749544820> Tj /F3 9.0 Tf 1 0 0 1 273.96 429.48 Tm <5355434820> Tj /F3 9.5 Tf 1 0 0 1 302.40 429.48 Tm <4150504C49434154494F4E20> Tj /F3 9.0 Tf 1 0 0 1 370.44 429.48 Tm <4F5220> Tj /F3 10.0 Tf 1 0 0 1 387.00 429.48 Tm <434C41494D2C20> Tj 1 0 0 1 424.08 429.84 Tm <4B4E4F57494E474C5920> Tj 1 0 0 1 488.52 429.48 Tm <4D414B455320> Tj /F3 9.5 Tf 1 0 0 1 526.68 429.12 Tm <4F52> Tj 1 0 0 1 47.88 417.96 Tm <4B4E4F57494E474C5920> Tj /F3 9.0 Tf 1 0 0 1 111.96 418.32 Tm <415353495354532C20> Tj /F3 9.5 Tf 1 0 0 1 155.52 418.32 Tm <41424554532C20> Tj /F3 9.0 Tf 1 0 0 1 192.96 418.32 Tm <534F4C49434954532C20> Tj /F3 8.5 Tf 1 0 0 1 241.20 418.32 Tm <4F5220> Tj /F3 9.0 Tf 1 0 0 1 257.04 418.32 Tm <434F4E53504952455320> Tj /F3 9.5 Tf 1 0 0 1 313.56 418.32 Tm <5749544820> Tj /F3 10.5 Tf 1 0 0 1 341.64 418.32 Tm <414E4F544D5220> Tj /F3 9.0 Tf 1 0 0 1 392.04 418.32 Tm <544F20> Tj /F3 10.0 Tf 1 0 0 1 407.52 418.32 Tm <4D414B4520> Tj 1 0 0 1 439.20 418.32 Tm <4120> Tj 1 0 0 1 449.28 418.32 Tm <464149534520> Tj /F3 9.0 Tf 1 0 0 1 482.04 418.32 Tm <5245504F525420> Tj 1 0 0 1 523.44 417.96 Tm <4F4620> Tj /F3 10.0 Tf 1 0 0 1 538.92 418.32 Tm <54497B45> Tj /F3 9.0 Tf 1 0 0 1 47.88 406.80 Tm <54484546542C20> Tj 1 0 0 1 83.52 406.80 Tm <4445535452554354494F4E2C20> Tj /F3 9.5 Tf 1 0 0 1 157.68 406.80 Tm <44414D41474520> Tj /F3 9.0 Tf 1 0 0 1 204.12 406.80 Tm <4F5220> Tj /F3 9.5 Tf 1 0 0 1 220.68 406.80 Tm <434F4E2127455253494F4E20> Tj /F3 8.5 Tf 1 0 0 1 286.56 406.80 Tm <4F4620> Tj /F3 10.0 Tf 1 0 0 1 301.68 407.16 Tm <414E5920> Tj /F3 9.0 Tf 1 0 0 1 326.16 406.80 Tm <4D4F544F5220> Tj /F3 9.5 Tf 1 0 0 1 364.32 407.16 Tm <56454849434C4520> Tj /F3 9.0 Tf 1 0 0 1 409.68 407.16 Tm <544F20> Tj /F3 9.5 Tf 1 0 0 1 425.52 407.16 Tm <4120> Tj /F3 10.0 Tf 1 0 0 1 435.24 407.16 Tm <4C415720> Tj /F3 9.5 Tf 1 0 0 1 460.08 406.80 Tm <454E464F5243454D454E54> Tj 1 0 0 1 47.88 395.28 Tm <4147454E43592C20> Tj 1 0 0 1 94.32 395.28 Tm <547D7B4520> Tj 1 0 0 1 115.92 395.28 Tm <4445504152544D454E5420> Tj /F3 8.5 Tf 1 0 0 1 185.76 395.28 Tm <4F4620> Tj /F3 9.0 Tf 1 0 0 1 200.88 395.28 Tm <4D4F544F5220> Tj 1 0 0 1 239.04 395.64 Tm <562C45497B4951492C455320> Tj /F3 8.5 Tf 1 0 0 1 289.44 395.64 Tm <4F5220> Tj /F3 10.0 Tf 1 0 0 1 305.64 395.64 Tm <414E20> Tj /F3 9.5 Tf 1 0 0 1 322.92 395.64 Tm <494E535552414E434520> Tj 1 0 0 1 382.32 395.64 Tm <434F4D50414E592C20> Tj /F3 10.0 Tf 1 0 0 1 437.04 395.28 Tm <434F4D4D545320> Tj /F3 9.5 Tf 1 0 0 1 486.00 395.28 Tm <4120> Tj /F3 10.0 Tf 1 0 0 1 495.72 395.28 Tm <465241454C26464E54> Tj /F3 9.0 Tf 1 0 0 1 47.88 383.76 Tm <494E53545D52414E434520> Tj /F3 9.5 Tf 1 0 0 1 106.56 384.12 Tm <4143542C20> Tj 1 0 0 1 132.12 384.12 Tm <574849434820> Tj /F3 8.5 Tf 1 0 0 1 168.48 383.76 Tm <495320> Tj /F3 10.0 Tf 1 0 0 1 179.64 384.12 Tm <4120> Tj /F3 9.5 Tf 1 0 0 1 189.72 384.12 Tm <4352494D452C20> Tj 1 0 0 1 226.08 384.12 Tm <414E4420> Tj 1 0 0 1 249.84 384.12 Tm <534841544C20> Tj 1 0 0 1 284.04 384.12 Tm <414C534F20> Tj /F3 9.0 Tf 1 0 0 1 312.84 384.12 Tm <424520> Tj 1 0 0 1 328.32 384.12 Tm <5355424A45435420> Tj 1 0 0 1 372.60 384.12 Tm <544F20> Tj /F3 10.0 Tf 1 0 0 1 388.44 384.12 Tm <4120> Tj /F3 9.0 Tf 1 0 0 1 398.52 384.12 Tm <435456494C20> Tj /F3 10.0 Tf 1 0 0 1 427.32 384.12 Tm <50454E4149545920> Tj /F3 9.5 Tf 1 0 0 1 474.48 383.76 Tm <4E4F5420> Tj 1 0 0 1 497.88 383.76 Tm <544F20> Tj 1 0 0 1 514.08 383.76 Tm <45584545454420> Tj /F3 8.5 Tf 1 0 0 1 556.20 383.76 Tm <46545645> Tj /F3 9.5 Tf 1 0 0 1 47.88 372.60 Tm <54484F5553414E4420> Tj 1 0 0 1 104.76 372.60 Tm <444F4C4C41525320> Tj /F3 10.0 Tf 1 0 0 1 153.00 372.60 Tm <414E4420> Tj /F3 9.5 Tf 1 0 0 1 177.84 372.60 Tm <54497B4520> Tj /F3 10.0 Tf 1 0 0 1 199.44 372.60 Tm <56414C554520> Tj /F3 8.0 Tf 1 0 0 1 235.80 372.60 Tm <4F4620> Tj /F3 10.0 Tf 1 0 0 1 250.20 372.60 Tm <547D494520> Tj /F3 9.0 Tf 1 0 0 1 272.52 372.60 Tm <5355424A45435420> Tj 1 0 0 1 317.16 372.60 Tm <4D4F544F5220> Tj /F3 9.5 Tf 1 0 0 1 355.32 372.60 Tm <56454849434C4520> Tj /F3 9.0 Tf 1 0 0 1 401.04 372.60 Tm <4F5220> Tj 1 0 0 1 417.60 372.60 Tm <53544154454420> Tj /F3 10.0 Tf 1 0 0 1 457.56 372.60 Tm <434C41494D20> Tj /F3 9.0 Tf 1 0 0 1 492.48 372.24 Tm <464F5220> Tj /F3 9.5 Tf 1 0 0 1 514.44 372.24 Tm <45414348> Tj /F3 10.0 Tf 1 0 0 1 47.88 361.08 Tm <56494F4C4154494F4E2E> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 99.72 316.08 Tm <285072696E7420> Tj 1 0 0 1 124.56 315.72 Tm <4E616D6520> Tj 1 0 0 1 151.56 315.72 Tm <6F6620> Tj /F3 8.5 Tf 1 0 0 1 162.36 315.72 Tm <50617469656E7429> Tj 0.00 Tc /F3 9.5 Tf 1 0 0 1 338.40 316.44 Tm <285369676E6174756520> Tj 1 0 0 1 382.32 315.72 Tm <6F6650617469656E7429> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 100.80 281.88 Tm <284164647265737320> Tj /F3 9.5 Tf 1 0 0 1 139.32 281.16 Tm <6F6650617469656E7429> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 346.32 279.36 Tm <4061746520> Tj /F3 9.5 Tf 1 0 0 1 370.44 281.16 Tm <6F6620> Tj /F3 9.0 Tf 1 0 0 1 381.60 281.16 Tm <5369676E617475726529> Tj 0.00 Tc 1 0 0 1 226.80 223.92 Tm <4E65756F6C6F672F20> Tj /F3 7.5 Tf 1 0 0 1 267.12 223.92 Tm <4173736F63696174657320> Tj /F3 8.5 Tf 1 0 0 1 308.16 223.92 Tm <6F6620> Tj /F3 7.5 Tf 1 0 0 1 318.24 223.92 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 340.92 223.92 Tm <42726F6F6B2220> Tj /F3 13.5 Tf 1 0 0 1 367.56 223.92 Tm <494946504320> Tj /F3 8.5 Tf 1 0 0 1 406.80 223.92 Tm <53746F727920> Tj /F3 8.0 Tf 1 0 0 1 429.84 223.92 Tm <42726F6F6B20> Tj /F3 7.5 Tf 1 0 0 1 454.32 223.92 Tm <50726576656E7469766520> Tj /F3 8.5 Tf 1 0 0 1 494.28 223.56 Tm <4D65646963696E652C20> Tj 1 0 0 1 533.52 223.56 Tm <494A495043> Tj /F3 8.0 Tf 1 0 0 1 226.80 213.84 Tm <4E657720> Tj /F3 8.5 Tf 1 0 0 1 246.24 213.48 Tm <596F726B20> Tj /F3 7.5 Tf 1 0 0 1 266.76 213.48 Tm <5370696E6520> Tj /F3 9.0 Tf 1 0 0 1 289.44 213.48 Tm <2620> Tj 1 0 0 1 298.44 213.48 Tm <42726169722120> Tj /F3 13.5 Tf 1 0 0 1 323.28 213.48 Tm <5554504320> Tj /F3 7.5 Tf 1 0 0 1 406.80 213.48 Tm <53746F6F7920> Tj /F3 8.0 Tf 1 0 0 1 429.84 213.48 Tm <42726F6F6B20> Tj 1 0 0 1 454.32 213.48 Tm <507379636869617472696320> Tj 1 0 0 1 496.08 213.12 Tm <4173736F6369617465732C20> Tj /F3 7.5 Tf 1 0 0 1 539.64 213.12 Tm <55465043> Tj 1 0 0 1 227.52 203.40 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 249.84 203.40 Tm <42726F6F6B20> Tj 1 0 0 1 274.32 203.40 Tm <526164696174696F6E20> Tj /F3 12.5 Tf 1 0 0 1 312.12 203.40 Tm <4F6E636F6C6F67792C494946504320> Tj /F3 7.5 Tf 1 0 0 1 406.80 203.40 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 429.84 203.04 Tm <42726F6F6B20> Tj /F3 8.5 Tf 1 0 0 1 453.96 203.04 Tm <526164696F6C6F672F2C20> Tj /F3 8.0 Tf 1 0 0 1 495.72 202.68 Tm <55465043> Tj /F3 7.5 Tf 1 0 0 1 227.52 192.96 Tm <53746F74727920> Tj /F3 8.0 Tf 1 0 0 1 249.84 192.96 Tm <42726F6F6B20> Tj 1 0 0 1 274.32 192.96 Tm <4173736F63696174657320> Tj 1 0 0 1 315.72 192.96 Tm <4F70687468616C6D6F6C6F72792C20> Tj /F3 10.0 Tf 1 0 0 1 375.84 192.60 Tm <5546504320> Tj /F3 7.5 Tf 1 0 0 1 406.80 192.96 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 429.84 192.60 Tm <42726F6F6B20> Tj /F3 8.5 Tf 1 0 0 1 454.68 192.60 Tm <5375676963616C20> Tj /F3 8.0 Tf 1 0 0 1 486.00 192.60 Tm <4173736F6369617465732C20> Tj 1 0 0 1 529.56 192.24 Tm <55465043> Tj /F3 8.5 Tf 1 0 0 1 227.52 182.52 Tm <53746F5B7920> Tj /F3 8.0 Tf 1 0 0 1 249.84 182.52 Tm <42726F6F6B20> Tj /F3 11.0 Tf 1 0 0 1 274.32 182.52 Tm <4F20> Tj /F3 8.0 Tf 1 0 0 1 286.56 182.52 Tm <686F70636469637320> Tj /F3 7.5 Tf 1 0 0 1 320.76 182.52 Tm <4173736F6369617465732C20> Tj /F3 13.5 Tf 1 0 0 1 363.60 182.52 Tm <5549504320> Tj /F3 7.5 Tf 1 0 0 1 406.80 182.52 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 429.84 182.52 Tm <42726F6F6B20> Tj 1 0 0 1 454.32 182.52 Tm <55726F6C6F67792C20> Tj /F3 7.5 Tf 1 0 0 1 488.52 182.16 Tm <4C49465043> Tj 1 0 0 1 227.52 172.08 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 249.84 172.44 Tm <42726F6F6B20> Tj 1 0 0 1 274.32 172.44 Tm <506174686F6C6F67697374732C20> Tj 1 0 0 1 323.28 172.08 Tm <4C69465043> Tj /F3 8.5 Tf 1 0 0 1 227.16 162.00 Tm <55647665726369747920> Tj /F3 7.5 Tf 1 0 0 1 266.76 162.00 Tm <4173736F63696174657320> Tj /F3 8.0 Tf 1 0 0 1 307.80 162.00 Tm <696E20> Tj 1 0 0 1 316.80 162.00 Tm <4F62737465747269637320> Tj /F3 9.5 Tf 1 0 0 1 355.68 162.00 Tm <2620> Tj /F3 8.0 Tf 1 0 0 1 365.04 161.64 Tm <47292C6E65636F6C6F67792C20> Tj 1 0 0 1 413.28 161.64 Tm <55465043> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 343.80 128.16 Tm <285369676E617475726520> Tj /F3 9.0 Tf 1 0 0 1 387.72 127.44 Tm <6F6620> Tj /F3 10.0 Tf 1 0 0 1 398.52 127.44 Tm <686F766964657229> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 99.72 247.32 Tm <284164636C7265737320> Tj /F3 9.0 Tf 1 0 0 1 138.24 246.60 Tm <6F6620> Tj 1 0 0 1 149.04 246.60 Tm <50617469656E7429> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 47.88 223.56 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 70.56 223.92 Tm <42726F6F6B20> Tj 1 0 0 1 95.04 223.92 Tm <416E657374686573696F6C6F67792C20> Tj 1 0 0 1 155.52 223.56 Tm <55465043> Tj /F3 7.5 Tf 1 0 0 1 47.88 213.48 Tm <53746F6F7920> Tj /F3 8.0 Tf 1 0 0 1 70.92 213.48 Tm <42726F6F6B20> Tj 1 0 0 1 95.40 213.48 Tm <4368696C6472657472277320> Tj /F3 7.5 Tf 1 0 0 1 134.28 213.48 Tm <536572766963652C20> Tj /F3 8.0 Tf 1 0 0 1 165.24 213.48 Tm <55465043> Tj /F3 7.5 Tf 1 0 0 1 47.88 203.04 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 70.56 203.40 Tm <42726F6F6B20> Tj 1 0 0 1 95.04 203.40 Tm <4465726D61746F6C6F677920> Tj 1 0 0 1 144.72 203.40 Tm <4173736F6369617465732C20> Tj 1 0 0 1 188.28 203.40 Tm <55465043> Tj /F3 7.5 Tf 1 0 0 1 47.88 192.60 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 70.56 192.96 Tm <42726F6F6B20> Tj 1 0 0 1 95.04 192.96 Tm <456D657267656E637920> Tj 1 0 0 1 138.24 192.96 Tm <50687973696369616E732C20> Tj 1 0 0 1 181.44 192.60 Tm <55465043> Tj /F3 7.5 Tf 1 0 0 1 47.88 182.16 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 70.56 182.52 Tm <42726F6F6B20> Tj /F3 9.0 Tf 1 0 0 1 95.04 182.52 Tm <466124696C7920> Tj /F3 8.5 Tf 1 0 0 1 122.76 182.52 Tm <4D65646963616C20> Tj /F3 8.0 Tf 1 0 0 1 154.80 182.52 Tm <47726F75702C20> Tj 1 0 0 1 182.16 182.52 Tm <314A495043> Tj /F3 7.5 Tf 1 0 0 1 47.88 172.08 Tm <53746F6E7920> Tj /F3 8.0 Tf 1 0 0 1 70.56 172.08 Tm <42726F6F6B20> Tj /F3 8.5 Tf 1 0 0 1 95.04 172.44 Tm <6874656D697374732C20> Tj /F3 7.5 Tf 1 0 0 1 133.20 172.08 Tm <4C49465043> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 47.52 81.72 Tm <502E4F2E20> Tj 1 0 0 1 68.76 81.72 Tm <426F7820> Tj 1 0 0 1 87.48 81.72 Tm <343137393738> Tj 0.00 Tc 1 0 0 1 47.88 70.20 Tm <426F73746F6E2E20> Tj /F3 11.5 Tf 1 0 0 1 81.72 70.56 Tm <4D4120> Tj /F3 9.0 Tf 1 0 0 1 103.32 70.56 Tm <30323234312D37393F38> Tj 1 0 0 1 77.40 59.40 Tm <284164647265737329> Tj /F3 8.5 Tf 1 0 0 1 47.16 40.68 Tm <4E595320> Tj /F3 8.0 Tf 1 0 0 1 67.68 40.68 Tm <464F524D20> Tj /F3 8.5 Tf 1 0 0 1 94.68 40.68 Tm <4E462D414F4220> Tj /F3 8.0 Tf 1 0 0 1 131.40 41.76 Tm <2852657620> Tj /F3 8.5 Tf 1 0 0 1 151.92 40.68 Tm <6C312F3230313529> Tj 0.00 Tc 1 0 0 1 343.80 93.96 Tm <284461746520> Tj /F3 9.5 Tf 1 0 0 1 368.28 92.88 Tm <6F6620> Tj /F3 8.5 Tf 1 0 0 1 379.44 92.88 Tm <5369676E617475726529> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 47.88 148.68 Tm <6C5072696E7420> Tj /F3 8.5 Tf 1 0 0 1 72.00 150.48 Tm <4E616D6520> Tj /F3 9.0 Tf 1 0 0 1 98.64 150.48 Tm <6F6620> Tj 1 0 0 1 109.08 150.84 Tm <50726F766964657229> Tj ET endstream endobj 14 0 obj << /Length 15 0 R >> stream Group# Patient Name: MR# Date: NEW YORI( MOTOR VEHICLE NO-FAI]LT INSIJRANCE LAWASSIGNMENT OF BENEFITS FORM I, (FOR ACCIDENTS OCCIIRING ON AND AFTER 3/1/02)("Assipor') hereby assign to (See Relow) , ("Assignee") all rights, (Prht patient's mme) (Print hospital or health care proyider narDe)privileges, and remedies to payment for health care services provided by assignee to which I am entitled under Article5 I (the No-Fault statute) of the Insurance Law. The Assignee hereby certifies that they have not received any payment from or on behalfofthe Assignor and shall notpursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on not withstanding any prior written agreement to the contuary. (Print accident date)This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack ofcoverage and/or violation ofa policy condition due to the actions or conduct ofthe assignor. A}IY PERSON WHO KNOMNGLY AND WITII INTENT TO DEFRAUD AI.{Y INST'RANCE COMPANY OR OTHERPERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANYCOMMERCIAL OR PERSONAL INST'P.ANCE BENEFITS CONTAINING ANY MATERIALLY FAISE INFORMATION, ORCONCEALS FOR THE PT,RPOSE OF MISLEADING, INFORMATION CONCERNINC A.I.TY FACT MATERIAL THERETO,AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES ORKNOWINGLY ASSISTS, ABETS, SOLICITS, OR CONSPIRES WITH ANOTMR TO MAKE A FAISE REPORT OF TI{ETHEFT, DESTRUCTION, DAMAGE OR CON!'ERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENTAGENCY, T}{E DEPARTMENT OF MOTOR V,EI{IQI,ES OR AN INSURANCE COMPANY, COMMTS A FRAEL&FNTINST]RANCE ACT, WHICH IS A CRIME, AND SHATL ALSO BE SUBJECT TO A CTVIL PENAITY NOT TO EXEEED FTVETHOUSAND DOLLARS AND TI{E VALUE OF T}IE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACHVIOLATION. (Print Name of Patient) (Signatue ofPatient) (Address ofPatient) @ate of Signature) Neuolog/ Associates of Stony Brook" IIFPC Story Brook Preventive Medicine, IJIPCNew York Spine & Brair! UTPC Stooy Brook Psychiatric Associates, UFPCStony Brook Radiation Oncology,IIFPC Stony Brook Radiolog/, UFPCStotry Brook Associates Ophthalmolory, UFPC Stony Brook Sugical Associates, UFPCSto[y Brook O hopcdics Associates, UIPC Stony Brook Urology, LIFPCStony Brook Pathologists, LiFPCUdvercity Associates in Obstetrics & G),necology, UFPC (Signature of hovider) (Adclress of Patient) Stony Brook Anesthesiology, UFPCStooy Brook Childretr's Service, UFPCStony Brook Dermatology Associates, UFPCStony Brook Emergency Physicians, UFPCStony Brook Fa$ily Medical Group, 1JIPCStony Brook htemists, LIFPC P.O. Box 417978 Boston. 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