gnature Metropolitan Correctional Center Official Count Slip Unit: Coca: Print Name: Signatarei Print Manic • Unit: Count: I. Print Name: I. Signature 2. Print Name 2. Signature: Nteiropoetaa CorrecThiaiial Cents, Official Count Slip Dote: Metropolitan Correctional Center New York, New York Of

call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signingbelow means that ve received and understand this notice. You also receive a copy. I. Signature: f. CMS does nontidimriminacia its programs and activities. To nest Ills nblicatlo alternative for please call: 1-800-MEDICARE or email: J. Date

re (Partnership) Stratums of ah general paltrier; (type 0' print names next to signatures) Print Name end Trtie • Data Print Name and Tine Date I. Signature (Entitles other than Partnerships) " IN !TRESS OF_, WHICH I have set my hand as Secretary (or other duly aurorae° officer) of this Entity on thi

ture (Parinerxhip) 5 onatu'es of a I Genera rortrers (type or p-nt names, next to signaures) Signature Sig'7i—rature Print toore and Title Title I. Signature (Entities other than Partnerships) IN WITNESS 01 WHICH I have set my hand as Secretory .or other duly authorized officer) of this Entity on this th

of at general partners (type or print names next to vgnatites) rz) Signature Print Name and Title Date Sigiustir itiiirt Name and Tide Date I. Signature (Entitles other then Partnerships) IN WITNESS OF WHICH I have set my hand as Secretary (or other duly authorized officer) of the Entity on this the