[or b.r..ow,,. t1.59/ NI )255 TN Cube rin1401 0 03 601 27B 73 NM ArkirbeNWithemmai 17,5417.101 390,S12• Instmont Income Onootnl 002 012 Inures! 000 1925 N44 Mmiretrewm Income 0.00 19.47 Pearr44 rx CU 4.41-ora on Cosh 01609) 1452492 unor•Ina ix Chin/Lan on Cow 0.515 Ill 00.402 IC

or be ran/ upOn f you bete. Ithre 6 an !era a *mop" please report a nmedately n twang to the Derr Maracpt of to office senrq rats 'cove. Alt.:utak Inures thorn we Mad* V> be acciado. Oaternert data tail nos be used lee la pecans Fay •C•tstron)eamd Ib Iona, De. Form 1099. 549:9. h"". etc )edwn fears,

fy) 20. Abuse. substance/ Physical / emotional 21 Nutntion 22 Other COMMENT: Abnormal Findings, by number B. HEALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli e Tuberculin test Sickle Cell type date result NAME:

Savings Account Summary Area Amid Nelikirla2e Yro11 Earned TT* Penal' 060\ flpiarång Illeline• ~1116111 Op«, 6 Credo 76132 Pmi Me 5784 32 Inures: %NW Nyman* å Trariden (1665061i 55.756 25 merest ml la 10 Om Ending ~nee $2.972.161.06 Ilminearge Yid! Frad n m.wmM.x..Mint •14 .rienvo,“fr

m 6. dues y redeem continuer cobrinsole names soar Ma CIIIMASEJ Otr,• V lomminsrms oue cametits us rip na tenni page el Magda 00 careen n: flinch Inures u attai cart.z telatianadas tonne mono. • Si lien re Mar Lite 7.14), is (wheel en WetTilft. ON!"es Tedmnietbv px ita St sr, salt • Poitemin splice

siness. Thank you lot being ala Guskynne. Provicvs Balance $ 5.364.31 Inietes1 Paid This Period S 1.31 )del Crethl(s) 10.000.00 Year to -Oaks Inures! Paid $ 9.98 Total Dobil(a) - 4.810.00 Annual Percentage Yield Earned 0.15 % Service Charge - 0.00 Average Golleclod Balance $ 11.347_92 In