00,000 la $5.000.000I $8.000.000 U Other. $ is Website: (STATE EXCEPTIONS: IN, FL, KS, PR, NY, SC, VA) PLEASE TELL US ABOUT YOURSELF I. Name: (First/Middle Initial/Last/DesignatiorTEThs U omo O mo CI aos ifrit ythq Shaliii 4( 2. Social Security Number 3. Date of Birth: 4. Ma)'ling Addr L.7/ t9C) C( (100 614/42