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12 <br />SFL"T~QN V i <br />PLea~ sotwn[t ebe tla0ewia~ ~ with >~r apldlatloa-: <br />1- 17itvo yeaas of tioe~l :t~aztaw. (If t6s Fnn bas bean in a:4ttet+ce fa lest thaw dune <br />S"cu'a. e~loee all fmapcid stat~ttawc.) <br />~. Pro forma balance ~ shoa-ing t!u fi~dd impact of the P~~ ~ by ~ <br />N.C. Departateat of <br />3. Sipatos~- s4ocatcats to wLetita ~- naaobet of a~,pterat or any principal has <br />bees iawlwd In a fmgm4iai morptttatiaa a 6t~nTarnpccy. or otbec siatation tDU led to <br />losses by ert:ditosa. bdnd bays, or W env~atar lawmits slkgigs fraud or ittrp~peiay. <br />t <br />4. 'i3ee Wdvex of C:oafu~otttiality Qty ~PIoY~+t Lmttaaoe lax Recozds. <br />s_ ~e iafot~don regvimd ua secaoo lV a~lrtxt~sin cotttfdaatia! as attlmed is the N_C <br />Garrrat Staatee I321~2 if the caapaay iadiedes its is coafideatial ai the titae of is <br />ietibal dissloatva: to tbp N,C. Dq~atttttseaR of C.ot~aare. Pbasc sip below if you want <br />the iufoltiOtatiOt~ yaa ~~ a ~ILbS~ttilt$ IZi SaCllOtl ~ LO t!a kGQ[ GOO~fiil. <br />$1~OatatO- <br />~1t~C: Prw~~~tt <br />`~ <br />l . <br />IMtc' SwY -1 ~,~~A.1 <br />8 Rtrited bJ99 <br /> <br />TUTAL P.03 <br />TOTAL P.03 <br />