able) Typed or printed name and address of the Investor: Telephone No.: Email address: Preferred method for receiving communications: K Email El Mail Specify address if different from prior column: Type of Entity (e.g. individual, corporation, estate, trust, partnership, tax exempt organization

(MO/DY/YR) Fee Charged For Fulfilling This Request (if applicable): S Name or Initials of Records Department Staff Member Processing This Request: El Mail Out O Will Pick Up 1- Medical Records Copy . 2 - Patient Copy 1 EFTA00313812