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Form 95 See 18 U.S.C. 287 1001. NSN 7540-00-634-4046 STANDARD FORM 95 REV. 2/2007 PRESCRIBED BY DEPT. OF JUSTICE 28 CFR 14. 13a. SIGNATURE OF CLAIMANT See instructions on reverse side. 13b. PHONE NUMBER OF PERSON SIGNING FORM 14. DATE OF SIGNATURE CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS CIVIL PENALTY FOR PRESENTING FRAUDULENT CLAIM The claimant is liable to the United States Government for a civil penalty of not less than 5 000 and not more than 10 000 plus 3 times the amount of damages sustained by the Government. See 31 U.S.C. 3729. Authorized for Local Reproduction Previous Edition is not Usable 95-109 Fine imprisonment or both. A CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN A FEDERAL AGENCY RECEIVES FROM A CLAIMANT HIS DULY AUTHORIZED AGENT OR LEGAL REPRESENTATIVE AN EXECUTED STANDARD FORM 95 OR OTHER WRITTEN NOTIFICATION OF AN INCIDENT ACCOMPANIED BY A CLAIM FOR MONEY Failure to completely execute this form or to supply the requested material within two years from the date the claim accrued may render your claim invalid. A claim is deemed presented when it is received by the appropriate agency not when it is mailed. If instruction is needed in completing this form the agency listed in item 1 on the reverse side may be contacted. Complete regulations pertaining to claims asserted under the Federal Tort Claims Act can be found in Title 28 Code of Federal Regulations Part 14. INSTRUCTIONS Please read carefully the instructions on the reverse side and supply information requested on both sides of this form* Use additional sheet s if necessary. See reverse side for additional instructions. CLAIM FOR DAMAGE INJURY OR DEATH 1. Submit to Appropriate Federal Agency 3. TYPE OF EMPLOYMENT MILITARY 4. DATE OF BIRTH FORM APPROVED OMB NO. 1105-0008 2. Name address of claimant and claimant s personal representative if any. See instructions on reverse. Number Street City State and Zip code. 5. MARITAL STATUS 6. DATE AND DAY OF ACCIDENT 7. TIME A. M. OR P. M. CIVILIAN 8. BASIS OF CLAIM State in detail the known facts and circumstances attending the damage injury or death identifying persons and property involved the place of occurrence and the cause thereof* Use additional pages if necessary. PROPERTY DAMAGE NAME AND ADDRESS OF OWNER IF OTHER THAN CLAIMANT Number Street City State and Zip Code. BRIEFLY DESCRIBE THE PROPERTY NATURE AND EXTENT OF THE DAMAGE AND THE LOCATION OF WHERE THE PROPERTY MAY BE INSPECTED. PERSONAL INJURY/WRONGFUL DEATH STATE THE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT STATE THE NAME OF THE INJURED PERSON OR DECEDENT. WITNESSES NAME ADDRESS Number Street City State and Zip Code AMOUNT OF CLAIM in dollars 12. See instructions on reverse. 12a* PROPERTY DAMAGE 12b. PERSONAL INJURY 12c* WRONGFUL DEATH 12d. TOTAL Failure to specify may cause forfeiture of your rights. I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM.

Wells fargo philanthropic serv... Wells Fargo Philanthropic Services Grant Application Instructions Wells Fargo Philanthropic Services provides grant administration services for various foundations. Guidelines, deadlines, and submission

Illinois standard health appli... Illinois Standard Health Employee Application for Small Employers For assistance in completing this application please contact your employer or insurance agent. GR-67834-49 1-11 Aetna Life Insurance Company NAIC No. 001-60054 Aetna Health Inc. NAIC No. 95109 V1 IL R-POD A ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER C Waiver of Coverage Please complete this section only if y o u a r e w a i v i n g d e c l i n i n g c o v e r a g e for yourself or one or more of your family members. Insurance carrier on the certificate of coverage/certificate of insurance. I hereby enroll for benefits as indicated in Section B and Section H of this application for which I am presently eligible or for which I may become eligible under my employer s group contract s. If any deductions are required for this coverage I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon written notice. to make decisions regarding eligibility enrollment underwriting and premium risk rating. A photographic copy of this acknowledgment shall be as valid as the original. I authorize the insurance carrier to electronically transmit the information contained herein. signature line of the application and I agree that such printing shall be treated as a valid signature for all purposes of this form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable law or regulation. By signing below I acknowledge that I have read and understand this document and I am signing of my own free will. Employee Signature Date For information about your health care rights under state and federal law and other resources please contact the Illinois Department of Insurance s Office of Consumer Health Insurance toll free at 877 527-9431. Alcohol drug or substance use or dependency N. Organ or bone marrow transplant If yes are multiples twins triplets etc. expected Are there any known complications or is a cesarean section planned 2 Are you your spouse/domestic partner or any dependent for whom you are requesting coverage currently pregnant Due Date MM/DD/YYYY 3 W i t h i n t h e p a s t 1 2 m o n t h s have you or your spouse/domestic partner used any tobacco products other than for the common cold or flu that is n o t i n d i c a t e d e l s e w h e r e i n this application diagnosed with had medical treatment recommended received medical treatment including prescription medications or been hospitalized for a n y i l l n e s s i n j u r y o r health condition not indicated above G Additional Information I f y o u a n s w e r e d Y e s t o any o f t h e q u e s t i o n s a b o v e y o u m u s t c o m p l e t e t h i s s e c t i o n. Question Number Name of Individual Condition/Diagnosis Treatment Received Treatment ongoing Date Diagnosed MM/YYYY Last Treatment Date Surgery additional tests or treatment recommended Medication Prescribed if any Currently taking medication Additional Coverage Options You should complete this section only if your employer offers any of the additional coverage options PPO HMO Dental HMO Office ID if applicable Amount if applicable Employee Class employer will provide you with this information if needed Salary if requesting life or disability coverage Hourly Weekly Monthly Semi-monthly Annually B e n e f i c i a r y I n f o r m a t i o n if requesting life insurance Primary Beneficiary Name Last First MI Relationship Benefit Secondary Beneficiary Name Last First MI Acknowledgement Signature I understand agree and represent that I have read this document or it has been read to me. The answers provided within this entire application for coverage are to the best of my knowledge and belief true and complete. Diabetes If yes check all that apply Non- Dependent Dependent Pump L. HIV positive AIDS diseases associated with AIDS lupus or other disorder of the immune system M. Alcohol drug or substance use or dependency N. Organ or bone marrow transplant If yes are multiples twins triplets etc. expected Are there any known complications or is a cesarean section planned 2 Are you your spouse/domestic partner or any dependent for whom you are requesting coverage currently pregnant Due Date MM/DD/YYYY 3 W i t h i n t h e p a s t 1 2 m o n t h s have you or your spouse/domestic partner used any tobacco products other than for the common cold or flu that is n o t i n d i c a t e d e l s e w h e r e i n this application diagnosed with had medical treatment recommended received medical treatment including prescription medications or been hospitalized for a n y i l l n e s s i n j u r y o r health condition not indicated above G Additional Information I f y o u a n s w e r e d Y e s t o any o f t h e q u e s t i o n s a b o v e y o u m u s t c o m p l e t e t h i s s e c t i o n. Question Number Name of Individual Condition/Diagnosis Treatment Received Treatment ongoing Date Diagnosed MM/YYYY Last Treatment Date Surgery additional tests or treatment recommended Medication Prescribed if any Currently taking medication Additional Coverage Options You should complete this section only if your employer offers any of the additional coverage options PPO HMO Dental HMO Office ID if applicable Amount if applicable Employee Class employer will provide you with this information if needed Salary if requesting life or disability coverage Hourly Weekly Monthly Semi-monthly Annually B e n e f i c i a r y I n f o r m a t i o n if requesting life insurance Primary Beneficiary Name Last First MI Relationship Benefit Secondary Beneficiary Name Last First MI Acknowledgement Signature I understand agree and represent that I have read this document or it has been read to me. INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period This standard application is intended to simplify your health insurance application process. You will only need to complete this one application even when your employer has requested quotes from multiple insurance companies. The information you provide in this application will be sent to the following insurance companies To be completed by employer Insurer TO BE COMPLETED BY EMPLOYER Employer Name Phone Address R e a s o n f o r E n r o l l m e n t Mark all that apply New Enrollment New Group Special Enrollment Adoption Court Order Loss of Coverage Employment Status Active New Hire Date Dependent Addition Marriage Newborn Retiree Retirement Date Illinois Continuation Employee Divorce / Domestic Partner Date of Event Other Late Enrollee COBRA Dependent Qualifying Event Start Date A Projected End Date Employee Information First Name Last Job Title MI Marital Status Married Single Widowed Hrs/Week Home Address Apt City State Home or Cell Phone Zip Business Phone Email Address optional B Coverage Requested Medical Yes Plan Choice No Spouse/Domestic Partner Child ren If you are w a i v i n g d e c l i n i n g coverage for yourself or any member of your family you must complete Section C below.

Printable forms to file a moti... This sample report form can help document the findings of a preliminary investigation into an accident or incident in your workplace. You can copy and use this form or make your own. Fill out an investigation

Online day planner form ONE DAY PLANNER THINGS TO DO DAY DATE DAILY SCHEDULE 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 NOTES * NOTES * NOTES * NOTES 4:30 5:00 5:30

Music is revolution email form The Michael Davis MUSIC IS REVOLUTION MINI-GRANT APPLICATION GUIDELINES Funding Provided by the MUSIC IS REVOLUTION Foundation and its Contributors The Music Is Revolution Foundation administers a mini-grant program for Music Is Revolution activities designed by teachers to implement support and/or improve their ability to provide quality music education for their students. If approved applicants should receive funds within 30 days. Mail or e-mail the application to Music Is Revolution Foundation P. Provide sufficient information to enable the Music Is Revolution Foundation Selection Committee to have a clear understanding of your project. Show the total budget for your project as well as the specific amount you are requesting from the Music Is Revolution Foundation. Evaluation Describe how you will measure the impact of this project i.e. changes/growth in the amount of time spent by students making music or listening to music greater understanding of the students about different genres of music cultures careers in music etc.. O. Box 11899 Portland OR 97211 grants musicisrevolution.com Date Teacher s Name School School District Grade s Principal Federal Tax ID School Address City State Phone s Zip Fax E-mail Name of Project Genre of Music Supported Number of Students Served By This Project List any Unique Characteristics of Students Approximate date s and/or Time Span of Project Total Cost of Project Total Music Is Revolution Mini-Grant Funding Requested Attach up to two pages including project description and budget. Mini-grants up to 500 are available to teachers for music education activities of all types. Only projects that clearly contain a music education focus that is projects based on the concept academic and cultural identity and humanizing them through the emotional cognitive and/or physical impact of music will be considered* Applicants are encouraged to include activities that expose students to genres and styles of music not likely to be experienced as a part of their normal daily lives and to plan the project with input from students parents and school administrators so that the project supports the imaginations of the students while maintaining relevance to the curriculum already in place. Funds may be used for supplies materials equipment transportation for a field trip and/or to bring a performer or musical group to the school* Funds may not be used to pay for personnel to replace state or local school funds or for celebration food and drinks. Applications for mini-grants are reviewed three times each year. Deadlines are January 15 April 15 and October 15. Applications received after a deadline will be reviewed in the subsequent grant cycle. Applicants will be notified about the status of their mini-grants within 60 days of each deadline. along with photographs and/or audio recordings be submitted to the Foundation within 30 days of completion of the project. WHO MAY APPLY Public school teachers of children in grades K-12 may apply for funding. Students and/or parents may participate in the writing of the application* PIFF 11.

Standard form 424d OMB Approval No. 0348-0042 ASSURANCES - CONSTRUCTION PROGRAMS Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing

Standard form 299 STANDARD FORM 299 6/99 Prescribed by DOI/USDA/DOT P. L. 96-487 and Federal Register Notice 5-22-95 FORM APPROVED OMB NO.

Form 299 STANDARD FORM 299 05/09 Prescribed by DOI/USDA/DOT P. L. 96-487 and Federal Register Notice 5-22-95 FORM APPROVED OMB NO. 6901 et seq. and its regulations. The term hazardous materials also includes any nuclear SF-299 page 2 or byproduct material as defined by the Atomic Energy Act of 1954 as amended 42 U.S.C. 0596-0082 APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS AND FACILITIES ON FEDERAL LANDS FOR AGENCY USE ONLY NOTE Before completing and filing the application the applicant should completely review this package and schedule a Application Number preapplication meeting with representatives of the agency responsible for processing the application* Each agency may have specific and unique requirements to be met in preparing and processing the application* Many times with the help of the agency representative the application can be completed at the preapplication meeting. Date Filed Name and address of applicant include zip code 2. Name title and address of authorized agent if different from item 1 include zip code 3. Telephone area code Applicant Authorized Agent 4. As applicant are you check one a* Individual b. Corporation c* Partnership/Association d. State Government/State Agency e. Local Government f* Federal Agency 5. Specify what application is for check one New authorization Renewing existing authorization No* Amend existing authorization No* Assign existing authorization No* Existing use for which no authorization has been received Other If checked complete supplemental page If checked provide details under item 7 6. If an individual or partnership are you a citizen s of the United States Yes No 7. Project description describe in detail a Type of system or facility e*g* canal pipeline road b related structures and facilities c physical specifications Length width grading etc* d term of years needed e time of year of use or operation f Volume or amount of product to be transported g duration and timing of construction and h temporary work areas needed for construction Attach additional sheets if additional space is needed* 8. Attach a map covering area and show location of project proposal 9. State or Local government approval 10. Nonreturnable application fee Attached Applied for Not required 11. Does project cross international boundary or affect international waterways Continued on page 2 No if yes indicate on map Page 2 of 4 12. Give statement of your technical and financial capability to construct operate maintain and terminate system for which authorization is being requested* 13a* Describe other reasonable alternative routes and modes considered* b. Why were these alternatives not selected c* Give explanation as to why it is necessary to cross Federal Lands. 14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. Specify number date code or name 15. Provide statement of need for project including the economic feasibility and items such as a cost of proposal construction operation and maintenance b estimated cost of next best alternative and c expected public benefits.

Standard form lll Federal Use Only Signature Print Name Title Telephone No. Date Authorized for Local Reproduction Standard Form - LLL EF. 15. Continuation Sheet s SF-LLL-A attached Yes No 16. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. A. Name and Address of Lobbying Entity if individual last name first name MI Individuals Performing Services including address of different from No. 10a. last name first name MI attach Continuation Sheet s SF-LLL-A if necessary 11. Amount of Payment check all that apply 13. Type of Payment check all that apply a. retainer actual planned b. one-time fee c. commission 12. Form of Payment check all that apply d. contingent fee a. cash e. deferred b. Approved by OMB 0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U*S*C. 1352 See reverse for public burden disclosure. Type of Federal Action a* b. c* d. e. f* Status of Federal Action contract grant cooperative agreement loan loan guarantee loan insurance a* bid/offer/application b. initial award c* post-award Name and Address of Reporting Entity Prime Subawardee Tier Report Type a* initial filing b. material change For Material Change Only Year Quarter date of last report If Reporting Entity in No* 4 is Subawardee Enter Name and Address of Prime if known Congressional District if known 6. Federal Department/Agency Federal Program Name/Description Federal Action Number if known CFDA Number if applicable Award Amount if known 10. a* Name and Address of Lobbying Entity if individual last name first name MI Individuals Performing Services including address of different from No* 10a* last name first name MI attach Continuation Sheet s SF-LLL-A if necessary 11. Amount of Payment check all that apply 13. Type of Payment check all that apply a* retainer actual planned b. one-time fee c* commission 12. Form of Payment check all that apply d. contingent fee a* cash e. deferred b. in-kind specify nature f* other specify value 14. Brief Description of Services Performed or to be Performed and Date s of Service including officer s employee s or Member s contacted for Payment indicated in Item 11. 15. Continuation Sheet s SF-LLL-A attached Yes No 16. Information requested through this form is authorized by title 31 U*S*C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U*S*C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection* Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than 10 000 and not more than 100 000 for each such failure. Approved by OMB 0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U*S*C. 1352 See reverse for public burden disclosure. Type of Federal Action a* b. c* d. e. f* Status of Federal Action contract grant cooperative agreement loan loan guarantee loan insurance a* bid/offer/application b.

Standard form 24 Released 6/13/99. Applicant's Statement of Disability Civil Service Retirement System In Connection With Disability Retirement Under the Civil Service Retirement System or the Federal Employees' Retirement

Standard form 294 2001 TELEPHONE NUMBER NUMBER STANDARD FORM 294 REV. 9/2001 Prescribed by GSA-FAR 48 CFR 53. 219 a GENERAL INSTRUCTIONS 1. SUBCONTRACTING REPORT FOR INDIVIDUAL CONTRACTS See instructions on reverse OMB No* 9000-0006 Expires 04/30/2004 Public reporting burden for this collection of information is estimated to average 9 hours per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to the FAR Secretariat MVP Acquisition Policy Division GSA Washington DC 20405. 3. DATE SUBMITTED 1. CORPORATION COMPANY OR SUBDIVISION COVERED a* COMPANY NAME b. STREET ADDRESS 4. REPORTING PERIOD FROM INCEPTION OF CONTRACT THRU YEAR c* CITY MAR 31 d. STATE e. ZIP CODE SEPT 30 5. TYPE OF REPORT 2. CONTRACTOR IDENTIFICATION NUMBER REGULAR FINAL REVISED 6. ADMINISTERING ACTIVITY Please check applicable box ARMY GSA NASA NAVY DOE OTHER FEDERAL AGENCY Specify AIR FORCE DEFENSE CONTRACT MANAGEMENT AGENCY 7. REPORT SUBMITTED AS Check one and provide appropriate number PRIME CONTRACT NUMBER SUBCONTRACT NUMBER 8. AGENCY OR CONTRACTOR AWARDING CONTRACT a* AGENCY S OR CONTRACTOR S NAME 9. DOLLARS AND PERCENTAGES IN THE FOLLOWING BLOCKS DO INCLUDE INDIRECT COSTS DO NOT INCLUDE INDIRECT COSTS SUBCONTRACT AWARDS TYPE 10a* 10b. SMALL BUSINESS CONCERNS Include SDB WOSB HBCU/MI HUBZone SB and VOSB Including Service-Disabled VOSB Dollar Amount and Percent of 10c LARGE BUSINESS CONCERNS Dollar Amount and Percent of 10c* 10c* TOTAL Sum of 10a and 10b. HUBZone SMALL BUSINESS HUBZone SB CONCERNS Dollar Amount and Percent of 10c* VETERAN-OWNED SMALL BUSINESS CONCERNS Includng Service-Disabled Veteran-Owned SB Concerns PERCENT HISTORICALLY BLACK COLLEGES AND UNIVERSITIES HBCU AND MINORITY INSTITUTIONS MI If applicable ACTUAL CUMULATIVE WHOLE DOLLARS WOMEN-OWNED SMALL BUSINESS WOSB CONCERNS SMALL DISADVANTAGED BUSINESS SDB CONCERNS Include HBCU/MI Dollar Amount and Percent of 10c* CURRENT GOAL SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS CONCERNS Dollar Amount and Percent 100. 0 17. REMARKS 18a* NAME OF INDIVIDUAL ADMINISTERING SUBCONTRACTING PLAN AREA CODE AUTHORIZED FOR LOCAL REPRODUCTION Previous edition is not usable 18b. This report is not required from small businesses. commercial plan has been approved nor from large businesses in the Department of Defense DOD Test Program for Negotiation of Comprehensive Subcontracting Plans. The Summary Subcontract Report SF 295 is required for contractors operating under one of these two conditions and should be submitted to the Government in accordance with the instructions on that form* 3. This form collects subcontract award data from prime contractors/subcontractors that a hold one or more contracts over 500 000 over 1 000 000 for construction of a public facility and b are required to report subcontracts awarded to Small Business SB Small Disadvantaged Business SDB Women-Owned Small Business WOSB HUBZone Small Business HUBZone SB Veteran-Owned Small Business VOSB and Service-Disabled Veteran-Owned Small Business concerns under a subcontracting plan* For the Department of Defense DOD the National Aeronautics and Space Administration NASA and the Coast Guard this form also collects subcontract award data for Historically Black Colleges and Universities HBCUs and Minority Institutions MIs.

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