{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff31507\deff0\stshfdbch31506\stshfloch31506\stshfhich31506\stshfbi31507\deflang1033\deflangfe1033\themelang1033\themelangfe0\themelangcs0{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f34\fbidi \froman\fcharset0\fprq2{\*\panose 02040503050406030204}Cambria Math;}
{\f37\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\flomajor\f31500\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbmajor\f31501\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhimajor\f31502\fbidi \froman\fcharset0\fprq2{\*\panose 00000000000000000000}Cambria{\*\falt Times New Roman};}
{\fbimajor\f31503\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\flominor\f31504\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbminor\f31505\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}
{\fbiminor\f31507\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f44\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\f45\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\f47\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f48\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f49\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f50\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\f51\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f52\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f414\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\f415\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}
{\f417\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\f418\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}{\f419\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\f420\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}
{\f421\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\f422\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\flomajor\f31508\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fhimajor\f31528\fbidi \froman\fcharset238\fprq2 Cambria CE{\*\falt Times New Roman};}{\fhimajor\f31529\fbidi \froman\fcharset204\fprq2 Cambria Cyr{\*\falt Times New Roman};}
{\fhimajor\f31531\fbidi \froman\fcharset161\fprq2 Cambria Greek{\*\falt Times New Roman};}{\fhimajor\f31532\fbidi \froman\fcharset162\fprq2 Cambria Tur{\*\falt Times New Roman};}
{\fhimajor\f31535\fbidi \froman\fcharset186\fprq2 Cambria Baltic{\*\falt Times New Roman};}{\fhimajor\f31536\fbidi \froman\fcharset163\fprq2 Cambria (Vietnamese){\*\falt Times New Roman};}
{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}
{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}
{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;
\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;\red0\green0\blue0;\red0\green0\blue0;\chyperlink\ctint255\cshade255\red0\green0\blue255;\red43\green87\blue154;\red230\green230\blue230;}
{\*\defchp \f31506\fs22 }{\*\defpap \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 }\noqfpromote {\stylesheet{\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 \snext0 \sqformat \spriority0 Normal;}{\*\cs10 \additive 
\ssemihidden \sunhideused \spriority1 Default Paragraph Font;}{\*
\ts11\tsrowd\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\trcbpat1\trcfpat1\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv \ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 \snext11 \ssemihidden \sunhideused Normal Table;}{\*\cs15 \additive 
\rtlch\fcs1 \af0 \ltrch\fcs0 \cf15 \sbasedon10 \ssemihidden \styrsid15952810 Placeholder Text;}{\*\cs16 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \ul\cf19 \sbasedon10 \sunhideused \styrsid7935152 Hyperlink;}{\*\cs17 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 
\cf20\chshdng0\chcfpat0\chcbpat21 \sbasedon10 \ssemihidden \sunhideused \styrsid7935152 Mention;}{\s18\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 
\f31506\fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 \snext18 \sqformat \spriority1 \styrsid7935152 No Spacing;}}{\*\rsidtbl \rsid2906579\rsid3242194\rsid4269105\rsid7042446\rsid7935152\rsid8336157\rsid8466879\rsid10255858\rsid13320949
\rsid14028083\rsid14767213\rsid15952810}{\mmathPr\mmathFont34\mbrkBin0\mbrkBinSub0\msmallFrac0\mdispDef1\mlMargin0\mrMargin0\mdefJc1\mwrapIndent1440\mintLim0\mnaryLim1}{\info{\author Murphy, Suzanne M}{\operator Maddox, Jen}
{\creatim\yr2021\mo11\dy22\hr14\min46}{\revtim\yr2021\mo11\dy22\hr14\min46}{\printim\yr2021\mo11\dy22\hr14\min46}{\version2}{\edmins1}{\nofpages1}{\nofwords127}{\nofchars730}{\nofcharsws856}{\vern7}}{\*\xmlnstbl {\xmlns1 http://schemas.microsoft.com/offic
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\asianbrkrule\rsidroot2906579\newtblstyruls\nogrowautofit\usenormstyforlist\noindnmbrts\felnbrelev\nocxsptable\indrlsweleven\noafcnsttbl\afelev\utinl\hwelev\spltpgpar\notcvasp\notbrkcnstfrctbl\notvatxbx\krnprsnet\cachedcolbal \nouicompat \fet0
{\*\wgrffmtfilter 2450}\nofeaturethrottle1\ilfomacatclnup0\enforceprot1\protlevel2\ltrpar \sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid4269105\sftnbj {\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2
\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang 
{\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\s18\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid4269105 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 
\f31506\fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af31507\afs32 \ltrch\fcs0 \b\fs32\insrsid7935152\charrsid4269105 RISK MANAGEMENT DIVISION}{\rtlch\fcs1 \af31507\afs32 \ltrch\fcs0 \b\fs32\insrsid4269105\charrsid4269105 
\par }\pard \ltrpar\s18\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7935152 {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\insrsid7935152\charrsid4269105 85 SHS
\par Augusta, ME  04333
\par (207) 287-3351
\par }\pard\plain \ltrpar\qc \li0\ri0\sa360\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid4269105 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\insrsid7935152\charrsid4269105 Form can be faxed to 287-4008 or email}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\insrsid4269105 ed}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\b\fs24\insrsid7935152\charrsid4269105  to }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105  HYPERLINK "mailto:scott.kibler@maine.gov" }}{\fldrslt {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\cs16\b\fs24\ul\cf19\insrsid7935152\charrsid4269105 scott.kibler@maine.gov}}}\sectd \ltrsect\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid4269105\sftnbj {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\insrsid7935152\charrsid4269105 .}{
\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\insrsid7935152 
\par }\pard \ltrpar\qc \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7935152 {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \b\fs24\ul\insrsid7935152\charrsid4269105 
(PLEASE WRITE LEGIBILY IF COMPLETING BY HAND)
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 Date of loss   }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507 \ltrch\fcs0 \cs15\cf15\insrsid7935152\charrsid10487508 Click or tap to enter a date.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 
\ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105  }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid3242194\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 Reported by  }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par Phone Number    }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14767213\charrsid4269105 Address or location of where incident occurred:}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105    }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 
\af31507\afs24 \ltrch\fcs0 \fs24\insrsid2906579\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 Loss }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14767213\charrsid4269105 d}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 etail}{
\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14767213\charrsid4269105 s}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105                  }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{
\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid2906579\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 Damages         }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 What contributed to loss             }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\cs15\fs24\cf15\insrsid15952810\charrsid4269105 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid10255858\charrsid4269105 Provide name and phone number of p}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14028083\charrsid4269105 erson}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid10255858\charrsid4269105  or e}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14028083\charrsid4269105 ntity }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid10255858\charrsid4269105 r}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid14028083\charrsid4269105 esponsible for }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid10255858\charrsid4269105 d}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid14028083\charrsid4269105 amages}{\rtlch\fcs1 \af31507\afs24 
\ltrch\fcs0 \fs24\insrsid13320949\charrsid4269105 :}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105        }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507 \ltrch\fcs0 
\cs15\cf15\insrsid15952810\charrsid10487508 Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 Name }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 and Phone Number }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 
\fs24\insrsid15952810\charrsid4269105 of person completing this form  }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \cs15\fs24\cf15\insrsid15952810\charrsid4269105 
Click or tap here to enter text.}{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid77616\charrsid4269105 }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid15952810\charrsid4269105 
\par 
\par }{\rtlch\fcs1 \af31507\afs24 \ltrch\fcs0 \fs24\insrsid7935152\charrsid4269105 
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