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re Physician (PCP) ID Number: PCP Name: (If an coistais patient of PCP, check "Yes".) O Yes O yes 0 Yes O Yes Check all that apply: O Domestic Penner O Full-time Student O Young Adult O Full4ime Student O Young Adult Prior Carrier Carrier: (List coverage prior to this.) Poky Number: From D

• Inpatient Sonsces Mental Healthcare Outpatient Sernces Prescription Drugs (Network Only Irv:heated) Mall Otte Ones Ancillary Benefits (Vision. Centel) Child Otani:trey An Provider websiie IltNetWOrk Unlimited NM 100% 32.500/15.000 NM $20 I $40 Cense 100% X-Ray: S90/ Latr 100: $200 Coon

ies El Check Ygds is a publicly poled partnership (PIP) s NQt thomenn capital gain foes) -2 ,Atsgtvottga as Net long-term capital gain Oat) E Penner's Identifying number 20.3161309 91) Collectibles (213%) gain doss) F Penmen name, address, city. stab, and ZIP code BLUE CHIP CAPITAL LLC 329 S

tc ). check here J Partner's share cl profit, loss, and capital: Beginning Ending Profit 1.1346999% 1.1346999% LOSS 1.4641288% 1.4641288% Centel 1.4641288% 1.4641288% K Partner's share of inabilities at year end: Nonrecourse 3,652. Ouallited nonrecou financing 135,488. O. Recourse

nes of value as as of a cortan date and me applied to UPS Financial Services on a regular basis by an independent vaLtmion I Ow. - Issuer, general Penner a sponsor marketed values, if any are supplied to the Finn:y[6o our. ordeal parolee a sponsor and may be calculated based on &feet Manuton Iran th

te ineetnwa seosilies (ix lading *fit particpation program and real estate imestmera taw securities) and thawed patios are generally hcfity Algid. Centel structured ;redacts have not been regained with the Securities and Exchaw Commas:an a undo any state wcurities laws We provide estimated vas for p