<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="6"><strong>CLAIM FOR REIMBURSEMENT</strong></td>
<td colspan="8">1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR</td>
<td colspan="5">2. VOUCHER NUMBER</td>
</tr>
<tr class="even">
<td colspan="6"><strong>FOR EXPENDITURES</strong></td>
<td colspan="8"><blockquote>
<p>OFFICE</p>
</blockquote></td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="6"><strong>ON OFFICIAL BUSINESS</strong></td>
<td colspan="8">     </td>
<td colspan="5">3. SCHEDULE NUMBER</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="8">     </td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="4"><strong>4. CLAIMANT</strong></td>
<td colspan="10"><em>Read the Privacy Act Statement on the back of this
form.</em></td>
<td colspan="5"><strong>5. PAID BY</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">a. NAME <em>(Last, first, middle initial)</em></td>
<td colspan="5">b. SOCIAL SECURITY NUMBER</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">     </td>
<td colspan="5">     </td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">c. MAILING ADDRESS (<em>Include Postal Code)</em></td>
<td colspan="5">d. OFFICE TELEPHONE NUMBER</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">     </td>
<td colspan="5">     </td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><strong>6. EXPENDITURES</strong> <em>(If fare claimed
in col. (g) exceeds charge for one person, show in col. (h) the number
of additional persons which accompanied the claimant.)</em></td>
</tr>
<tr class="odd">
<td colspan="2">DATE</td>
<td></td>
<td colspan="5"><em>Show appropriate code in col. (b</em>):</td>
<td colspan="4"></td>
<td colspan="2">MILAGE</td>
<td colspan="5"><strong>AMOUNT CLAIMED</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="5">A - Local travel</td>
<td colspan="4"></td>
<td colspan="2">RATE</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">(Year)</td>
<td></td>
<td colspan="5">B - Telephone or telegraph, or</td>
<td colspan="4"></td>
<td colspan="2"></td>
<td></td>
<td>FARE</td>
<td colspan="2">ADD</td>
<td>TIPS AND</td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td></td>
<td colspan="5">C - Other Expenses (Itemized)</td>
<td colspan="4"></td>
<td colspan="2">      ¢</td>
<td>MILEAGE</td>
<td>OR TOLL</td>
<td colspan="2">PER-</td>
<td>MISCEL-</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td></td>
<td colspan="9"><em>(Explain expenditures in specific detail.)</em></td>
<td colspan="2">NO. OF MILES</td>
<td></td>
<td></td>
<td colspan="2">SONS</td>
<td>LANEOUS</td>
</tr>
<tr class="even">
<td colspan="2">(a)</td>
<td>(b)</td>
<td colspan="5">(c) FROM</td>
<td colspan="4">(d) TO</td>
<td colspan="2">(e)</td>
<td>(f)</td>
<td>(g)</td>
<td colspan="2">(h)</td>
<td>(i)</td>
</tr>
<tr class="odd">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><p>     </p>
<p>     </p></td>
<td><p>  </p>
<p>  </p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="8"><em>If additional space is required continue on the
back.</em></td>
<td colspan="4"><strong>SUBTOTALS CARRIED FORWARD FROM THE
BACK</strong></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="5"><strong>7. AMOUNT CLAIMED</strong> (Total of cols.
(f),(g) and (i).)</td>
<td colspan="4"><strong>&gt;</strong> $      </td>
<td colspan="3"><strong>TOTALS</strong></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td colspan="2">   </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="9">8. This claim is approved. Long distance telephone
calls, if shown, are certified as necessary in the interest of the
Government. <em>(Note: If long distance calls are included, the
approving official must have been authorized, in writing, by the head of
the department or agency to so certify (31 U&gt;S&gt;C.
680a).)</em></td>
<td colspan="10"><p>10. I certify that this claim is true and correct to
the best of my knowledge and belief and that payment or credit has not
been received by me.</p>
<p>PAYMENT DESIRED <em>Sign Original Only</em></p></td>
</tr>
<tr class="even">
<td colspan="9"></td>
<td colspan="10"> CHECK CASH</td>
</tr>
<tr class="odd">
<td colspan="9"><em>Sign Original Only</em></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2">DATE</td>
</tr>
<tr class="even">
<td colspan="2">APPROVING</td>
<td colspan="5"><strong>&gt;</strong></td>
<td colspan="2">DATE</td>
<td colspan="2"><p>CLAIMANT</p>
<p>SIGN HERE</p></td>
<td colspan="6"><strong>&gt;</strong></td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">OFFICIAL</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td>11.</td>
<td colspan="9">CASH PAYMENT RECEIPT</td>
</tr>
<tr class="even">
<td colspan="2">SIGN HERE</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="8">a. PAYEE <em>(Signature)</em></td>
<td colspan="2">b. DATE</td>
</tr>
<tr class="odd">
<td colspan="9">9. This claim is certified correct and proper for
payment.</td>
<td colspan="8"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="9"></td>
<td colspan="8"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Sign Original Only</em></td>
<td colspan="2">DATE</td>
<td colspan="8"></td>
<td colspan="2">c. AMOUNT</td>
</tr>
<tr class="even">
<td colspan="2">APPROVING</td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="8"></td>
<td colspan="2">$</td>
</tr>
<tr class="odd">
<td colspan="2"><p>OFFICIAL</p>
<p>SIGN HERE</p></td>
<td colspan="5"><strong>&gt;</strong></td>
<td colspan="2"></td>
<td colspan="4">12. PAYMENT MADE BY CHECK NO.</td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="19">ACCOUNTING CLASSIFICATION      </td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="10"><p><strong>STANDARD FORM 1164</strong> (REV. 11-77)</p>
<p>Prescribed by GSA, FPMR (CFR 41) 101-7</p></td>
</tr>
</tbody>
</table>

+-----+---+-----------------+--------------+-----+----+----+---+-----+
| *   |   |                 |              |     |    |    |   |     |
| *6. |   |                 |              |     |    |    |   |     |
| EX  |   |                 |              |     |    |    |   |     |
| PEN |   |                 |              |     |    |    |   |     |
| DIT |   |                 |              |     |    |    |   |     |
| URE |   |                 |              |     |    |    |   |     |
| S - |   |                 |              |     |    |    |   |     |
| Co  |   |                 |              |     |    |    |   |     |
| nti |   |                 |              |     |    |    |   |     |
| nue |   |                 |              |     |    |    |   |     |
| d** |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
| D   |   | *Show           |              | MIL | ** |    |   |     |
| ATE |   | appropriate     |              | AGE | AM |    |   |     |
|     |   | code in col.    |              |     | OU |    |   |     |
|     |   | (b*):           |              |     | NT |    |   |     |
|     |   |                 |              |     | C  |    |   |     |
|     |   |                 |              |     | LA |    |   |     |
|     |   |                 |              |     | IM |    |   |     |
|     |   |                 |              |     | ED |    |   |     |
|     |   |                 |              |     | ** |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   | A - Local       |              | R   |    |    |   |     |
|     |   | travel          |              | ATE |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
| (Ye |   | B - Telephone   |              |     |    | FA | A | T   |
| ar) |   | or telegraph,   |              |     |    | RE | D | IPS |
|     |   | or              |              |     |    |    | D | AND |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   | C - Other       |              |     | M  | OR | P | M   |
|     |   | Expenses        |              |     | IL | TO | E | ISC |
|     |   | (Itemized)      |              | ¢   | EA | LL | R | EL- |
|     |   |                 |              |     | GE |    | - |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   | *(Explain       |              | NO. |    |    | S | L   |
|     |   | expenditures in |              | OF  |    |    | O | ANE |
|     |   | specific        |              | MI  |    |    | N | OUS |
|     |   | detail.)*       |              | LES |    |    | S |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
| \(  | \ | \(c\) FROM      | \(d\) TO     | \(  | \  | \  | \ | \(  |
| a\) | ( |                 |              | e\) | (f | (g | ( | i\) |
|     | b |                 |              |     | \) | \) | h |     |
|     | \ |                 |              |     |    |    | \ |     |
|     | ) |                 |              |     |    |    | ) |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+
|     |   |                 |              |     |    |    |   |     |
|     |   |                 |              |     |    |    |   |     |
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| age |   |                 |              |     |    |    |   |     |
| nci |   |                 |              |     |    |    |   |     |
| es, |   |                 |              |     |    |    |   |     |
| w   |   |                 |              |     |    |    |   |     |
| hen |   |                 |              |     |    |    |   |     |
| re  |   |                 |              |     |    |    |   |     |
| lev |   |                 |              |     |    |    |   |     |
| ant |   |                 |              |     |    |    |   |     |
| to  |   |                 |              |     |    |    |   |     |
| civ |   |                 |              |     |    |    |   |     |
| il, |   |                 |              |     |    |    |   |     |
| cri |   |                 |              |     |    |    |   |     |
| min |   |                 |              |     |    |    |   |     |
| al, |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| r   |   |                 |              |     |    |    |   |     |
| egu |   |                 |              |     |    |    |   |     |
| lat |   |                 |              |     |    |    |   |     |
| ory |   |                 |              |     |    |    |   |     |
| in  |   |                 |              |     |    |    |   |     |
| ves |   |                 |              |     |    |    |   |     |
| tig |   |                 |              |     |    |    |   |     |
| ati |   |                 |              |     |    |    |   |     |
| ons |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| p   |   |                 |              |     |    |    |   |     |
| ros |   |                 |              |     |    |    |   |     |
| ecu |   |                 |              |     |    |    |   |     |
| tio |   |                 |              |     |    |    |   |     |
| ns, |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| w   |   |                 |              |     |    |    |   |     |
| hen |   |                 |              |     |    |    |   |     |
| pu  |   |                 |              |     |    |    |   |     |
| rsu |   |                 |              |     |    |    |   |     |
| ant |   |                 |              |     |    |    |   |     |
| to  |   |                 |              |     |    |    |   |     |
| a   |   |                 |              |     |    |    |   |     |
| re  |   |                 |              |     |    |    |   |     |
| qui |   |                 |              |     |    |    |   |     |
| rem |   |                 |              |     |    |    |   |     |
| ent |   |                 |              |     |    |    |   |     |
| by  |   |                 |              |     |    |    |   |     |
| t   |   |                 |              |     |    |    |   |     |
| his |   |                 |              |     |    |    |   |     |
| age |   |                 |              |     |    |    |   |     |
| ncy |   |                 |              |     |    |    |   |     |
| in  |   |                 |              |     |    |    |   |     |
| c   |   |                 |              |     |    |    |   |     |
| onn |   |                 |              |     |    |    |   |     |
| ect |   |                 |              |     |    |    |   |     |
| ion |   |                 |              |     |    |    |   |     |
| w   |   |                 |              |     |    |    |   |     |
| ith |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| hir |   |                 |              |     |    |    |   |     |
| ing |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| fir |   |                 |              |     |    |    |   |     |
| ing |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| an  |   |                 |              |     |    |    |   |     |
| emp |   |                 |              |     |    |    |   |     |
| loy |   |                 |              |     |    |    |   |     |
| ee, |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| is  |   |                 |              |     |    |    |   |     |
| sua |   |                 |              |     |    |    |   |     |
| nce |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| a   |   |                 |              |     |    |    |   |     |
| se  |   |                 |              |     |    |    |   |     |
| cur |   |                 |              |     |    |    |   |     |
| ity |   |                 |              |     |    |    |   |     |
| c   |   |                 |              |     |    |    |   |     |
| lea |   |                 |              |     |    |    |   |     |
| ran |   |                 |              |     |    |    |   |     |
| ce, |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| in  |   |                 |              |     |    |    |   |     |
| ves |   |                 |              |     |    |    |   |     |
| tig |   |                 |              |     |    |    |   |     |
| ati |   |                 |              |     |    |    |   |     |
| ons |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| pe  |   |                 |              |     |    |    |   |     |
| rfo |   |                 |              |     |    |    |   |     |
| rma |   |                 |              |     |    |    |   |     |
| nce |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| fic |   |                 |              |     |    |    |   |     |
| ial |   |                 |              |     |    |    |   |     |
| d   |   |                 |              |     |    |    |   |     |
| uty |   |                 |              |     |    |    |   |     |
| wh  |   |                 |              |     |    |    |   |     |
| ile |   |                 |              |     |    |    |   |     |
| in  |   |                 |              |     |    |    |   |     |
| G   |   |                 |              |     |    |    |   |     |
| ove |   |                 |              |     |    |    |   |     |
| rnm |   |                 |              |     |    |    |   |     |
| ent |   |                 |              |     |    |    |   |     |
| se  |   |                 |              |     |    |    |   |     |
| rvi |   |                 |              |     |    |    |   |     |
| ce. |   |                 |              |     |    |    |   |     |
| Y   |   |                 |              |     |    |    |   |     |
| our |   |                 |              |     |    |    |   |     |
| Soc |   |                 |              |     |    |    |   |     |
| ial |   |                 |              |     |    |    |   |     |
| Se  |   |                 |              |     |    |    |   |     |
| cur |   |                 |              |     |    |    |   |     |
| ity |   |                 |              |     |    |    |   |     |
| A   |   |                 |              |     |    |    |   |     |
| cco |   |                 |              |     |    |    |   |     |
| unt |   |                 |              |     |    |    |   |     |
| Num |   |                 |              |     |    |    |   |     |
| ber |   |                 |              |     |    |    |   |     |
| (S  |   |                 |              |     |    |    |   |     |
| SN) |   |                 |              |     |    |    |   |     |
| is  |   |                 |              |     |    |    |   |     |
| sol |   |                 |              |     |    |    |   |     |
| ici |   |                 |              |     |    |    |   |     |
| ted |   |                 |              |     |    |    |   |     |
| un  |   |                 |              |     |    |    |   |     |
| der |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| aut |   |                 |              |     |    |    |   |     |
| hor |   |                 |              |     |    |    |   |     |
| ity |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| In  |   |                 |              |     |    |    |   |     |
| ter |   |                 |              |     |    |    |   |     |
| nal |   |                 |              |     |    |    |   |     |
| R   |   |                 |              |     |    |    |   |     |
| eve |   |                 |              |     |    |    |   |     |
| nue |   |                 |              |     |    |    |   |     |
| C   |   |                 |              |     |    |    |   |     |
| ode |   |                 |              |     |    |    |   |     |
| (26 |   |                 |              |     |    |    |   |     |
| U.S |   |                 |              |     |    |    |   |     |
| .C. |   |                 |              |     |    |    |   |     |
| 6   |   |                 |              |     |    |    |   |     |
| 011 |   |                 |              |     |    |    |   |     |
| (b) |   |                 |              |     |    |    |   |     |
| and |   |                 |              |     |    |    |   |     |
| 61  |   |                 |              |     |    |    |   |     |
| 09) |   |                 |              |     |    |    |   |     |
| and |   |                 |              |     |    |    |   |     |
| E   |   |                 |              |     |    |    |   |     |
| .O. |   |                 |              |     |    |    |   |     |
| 93  |   |                 |              |     |    |    |   |     |
| 97, |   |                 |              |     |    |    |   |     |
| No  |   |                 |              |     |    |    |   |     |
| vem |   |                 |              |     |    |    |   |     |
| ber |   |                 |              |     |    |    |   |     |
| 22, |   |                 |              |     |    |    |   |     |
| 19  |   |                 |              |     |    |    |   |     |
| 43, |   |                 |              |     |    |    |   |     |
| for |   |                 |              |     |    |    |   |     |
| use |   |                 |              |     |    |    |   |     |
| as  |   |                 |              |     |    |    |   |     |
| a   |   |                 |              |     |    |    |   |     |
| ta  |   |                 |              |     |    |    |   |     |
| xpa |   |                 |              |     |    |    |   |     |
| yer |   |                 |              |     |    |    |   |     |
| and |   |                 |              |     |    |    |   |     |
| /or |   |                 |              |     |    |    |   |     |
| em  |   |                 |              |     |    |    |   |     |
| plo |   |                 |              |     |    |    |   |     |
| yee |   |                 |              |     |    |    |   |     |
| id  |   |                 |              |     |    |    |   |     |
| ent |   |                 |              |     |    |    |   |     |
| ifi |   |                 |              |     |    |    |   |     |
| cat |   |                 |              |     |    |    |   |     |
| ion |   |                 |              |     |    |    |   |     |
| n   |   |                 |              |     |    |    |   |     |
| umb |   |                 |              |     |    |    |   |     |
| er; |   |                 |              |     |    |    |   |     |
| d   |   |                 |              |     |    |    |   |     |
| isc |   |                 |              |     |    |    |   |     |
| los |   |                 |              |     |    |    |   |     |
| ure |   |                 |              |     |    |    |   |     |
| is  |   |                 |              |     |    |    |   |     |
| MAN |   |                 |              |     |    |    |   |     |
| DAT |   |                 |              |     |    |    |   |     |
| ORY |   |                 |              |     |    |    |   |     |
| on  |   |                 |              |     |    |    |   |     |
| vo  |   |                 |              |     |    |    |   |     |
| uch |   |                 |              |     |    |    |   |     |
| ers |   |                 |              |     |    |    |   |     |
| cl  |   |                 |              |     |    |    |   |     |
| aim |   |                 |              |     |    |    |   |     |
| ing |   |                 |              |     |    |    |   |     |
| p   |   |                 |              |     |    |    |   |     |
| aym |   |                 |              |     |    |    |   |     |
| ent |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| r   |   |                 |              |     |    |    |   |     |
| eim |   |                 |              |     |    |    |   |     |
| bur |   |                 |              |     |    |    |   |     |
| sem |   |                 |              |     |    |    |   |     |
| ent |   |                 |              |     |    |    |   |     |
| wh  |   |                 |              |     |    |    |   |     |
| ich |   |                 |              |     |    |    |   |     |
| is, |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| may |   |                 |              |     |    |    |   |     |
| be, |   |                 |              |     |    |    |   |     |
| t   |   |                 |              |     |    |    |   |     |
| axa |   |                 |              |     |    |    |   |     |
| ble |   |                 |              |     |    |    |   |     |
| s   |   |                 |              |     |    |    |   |     |
| upp |   |                 |              |     |    |    |   |     |
| ort |   |                 |              |     |    |    |   |     |
| the |   |                 |              |     |    |    |   |     |
| cl  |   |                 |              |     |    |    |   |     |
| aim |   |                 |              |     |    |    |   |     |
| may |   |                 |              |     |    |    |   |     |
| res |   |                 |              |     |    |    |   |     |
| ult |   |                 |              |     |    |    |   |     |
| in  |   |                 |              |     |    |    |   |     |
| de  |   |                 |              |     |    |    |   |     |
| lay |   |                 |              |     |    |    |   |     |
| or  |   |                 |              |     |    |    |   |     |
| l   |   |                 |              |     |    |    |   |     |
| oss |   |                 |              |     |    |    |   |     |
| of  |   |                 |              |     |    |    |   |     |
| re  |   |                 |              |     |    |    |   |     |
| imb |   |                 |              |     |    |    |   |     |
| urs |   |                 |              |     |    |    |   |     |
| eme |   |                 |              |     |    |    |   |     |
| nt. |   |                 |              |     |    |    |   |     |
+-----+---+-----------------+--------------+-----+----+----+---+-----+

STANDARD FORM 1164 (REV. 11-77) BACK