CERTIFICATION AND SIGNATURE. This is to certify that the person named above meets all the eligibility criteria for the Household Member. I understand that I will be responsible for paying any costs for enrollment in the plan and any taxes associated with enrolling a Household Member.* I also understand that any information falsified on this document may result in discipline up to and including termination from employment. Faculty Member Name: IN: (First, Middle Initial, Last) Faculty Member Signature: Date: *The Employer cost of providing health benefits for Household Members is considered ordinary income and is, therefore, subject to taxes, including social security, Medicare, federal and state taxes. AFFIDAVIT OF TERMINATION OF BENEFITS FOR HOUSEHOLD MEMBER I, , affirm the health benefit coverage for my Household Member (Print name of faculty/staff member) listed on the Enrollment Form dated , should be terminated as of . Termination of coverage for my Household Member is due to (check one): Household Member no longer meets the required eligibility criteria Death of Household Member Coverage no longer needed by the Household Member (obtained other coverage) I HEREBY AGREE TO MAIL A COPY OF THIS AFFIDAVIT TO MY SURVIVING FORMER HOUSEHOLD MEMBER. Faculty/Staff Member Signature Date Appendix D NAME: DATE: DEPARTMENT: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPORT Evaluation Period (1-2 Calendar Years) This is a confidential evaluation report on a member of the Northern Michigan University faculty. Its content will not be divulged to persons not authorized to help prepare or read this report. Access to the personnel file of any member of the faculty shall be restricted to the faculty member, his/her department head, departmental evaluation committee, xxxx, College Advisory Council, FRC, PVPAA, President of the University, the Board of Trustees and its counsel, and other persons who have a legal reason to know the contents of the evaluation. Evaluation Period: Tenured Full Professors will be evaluated every five years; other faculty will be evaluated annually. A Tenured Full Professor, the departmental evaluation committee, or the department head may request an annual evaluation. Faculty evaluation is described in the NMU/AAUP Agreement in Sections 5.4 through 5.6 and Article VI. Style: Writing in the evaluations is to be a narrative that is to the point and supported with evidence. NAME POSITION DATE Committee Members: Others: NORTHERN MICHIGAN UNIVERSITY FACULTY EVALUATION REPO...
CERTIFICATION AND SIGNATURE. Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below.
CERTIFICATION AND SIGNATURE. I permit the DU Office of Financial Aid to reduce or increase my student budget, thus changing my financial aid eligibility. I understand that I am responsible for ensuring that this form is complete prior to being submitted to the DU Office of Financial Aid. I understand that financial aid funds cannot be disbursed to me prior to the scheduled disbursement date for the term(s) I will be participating in the consortium program. Student Signature Date Student Name: DU ID: Host School ID or SSN:
CERTIFICATION AND SIGNATURE. Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. -------------------------------------------------------------------------------- a. TYPED NAME OF b. TITLE c. TELEPHONE (Include Area Code) CERTIFYING OFFICIAL Contracting Officer for Willxxx X. Xxxbxxx Xx. Xecurity Matters 301-000-0000 -------------------------------------------------------------------------------- d. ADDRESS (Include Zip Code) 17. REQUIRED DISTRIBUTION Code 7.4.1, Bldg 2109 [ ] a. CONTRACTOR Naval Air Warfare Center [ ] b. SUBCONTRACTOR Patuxent River MD 20670 [ ] c. COGNIZANT SECURITY OFFICE FOR PRIME AND ------------------------------- SUBCONTRACTOR [ ] d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS e. SIGNATURE SECURITY ADMINISTRATION [ ] e. ADMINISTRATIVE CONTRACTING OFFICE* [ ] f. OTHERS AS NECESSARY -------------------------------------------------------------------------------- DD Form 254 Reverse, DEC 90 N00019-96-D-2047 ATTACHMENT (4) 178 ATTACHMENT (7) Price Proposal Mannxxx - Xy CLIN 179 ATTACHMENT(7) N00019-96-R-0026 PRICE PROPOSAL MANNXXX - BY CLIN 0X01AA
CERTIFICATION AND SIGNATURE. I understand that I will be held as legally bound, obligated, and responsible by the use of my electronic signature as I would be by a handwritten signature and that legal action can be taken against me based on my use of the electronic signature in submitting electronic documents. Signature Date
CERTIFICATION AND SIGNATURE. By signing this Agreement, I make the following certifications: • I hereby authorize my bank to debit the bank account identified above and authorize Pension Fund to accept these deposits. These debits and deposits are to be made under the Rules of the Automated Clearing House (ACH). • I certify that the information provided on this Agreement is accurate and that I will timely notify Pension Fund of any changes to the information provided on this Agreement. • I understand that this Agreement will remain in effect until I give written notice of termination to Pension Fund. • I understand that this Agreement will be processed as soon as administratively practicable upon the later of receipt by Pension Fund or the requested effective date provided in Section II. Signature Date / / Printed Name SEND FORM TO: Please allow up to 5 business days for processing. Pension Fund of the Christian Church P.O. Box 6251, Indianapolis, IN 00000-0000 Toll Free Phone: 0.000.000.0000 • Phone: 000.000.0000 • Fax: 000.000.0000
CERTIFICATION AND SIGNATURE. By my signature below, I understand, agree and/or confirm that:
CERTIFICATION AND SIGNATURE. I certify that I will use the stipend requested toward the business use designated above. I further certify that I have read, understood and intend to comply with University-issued Cell Phones and Wireless Communication Stipend Policy. Signature_______________________________________________Date_______________________
CERTIFICATION AND SIGNATURE. By submitting this Claim Form, I certify that this information is true and correct. Signature Date / / (Month) (Day) (Year) III. MAIL THIS CLAIM FORM TO: Capital One TCPA Settlement Claims Administrator X.X. Xxx 00000 Xxxxxxxx, XX 00000 [(50445-001)] 453870 US.54324942.01 EXHIBIT B1 Email Notice Email Subject: Notice of Class Action Settlement Email Text:
CERTIFICATION AND SIGNATURE. By signing this Claims Form, Authorized Representative represents and warrants the following on behalf of the Settlement Class Member: · The Authorized Representative has authority to submit a claim and to release all Released Claims on behalf of the Settlement Class Member and all other Persons who are Releasing Persons by virtue of their relationship or association with the Settlement Class Member. · The Settlement Class Member has tested each of its Water Sources for PFAS. · The Settlement Class Member authorizes the Claims Administrator and/or Special Master to provide all Claims Form information, including PFAS test result details, to the relevant Parties as required by the terms of the Settlement Agreement. · The Settlement Class Member has consulted with any other entity that has incurred costs in connection with efforts to removed PFAS from, or prevent PFAS from entering, Settlement Class Member's Public Water System, and that Settlement Class Member's claim is on behalf of any such other entity. I declare under penalty of perjury subject to 28 U.S.C. § 1746 that all of the information provided within this Testing Compensation Claims Form and its attachments are true and correct to the best of my knowledge, information, and belief. Authorized Representative's Signature: Authorized Representative's Printed Name: Executed this day of at (County), (State). EXHIBIT B Notice of Proposed Class Action Settlement and Court Approval Hearing [Proposed Order begins on following page.] UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA CHARLESTON DIVISION IN RE: AQUEOUS FILM-FORMING FOAMS PRODUCTS LIABILITY LITIGATION MDL No. 2:18-mn-2873-RMG This Document relates to: City of Camden, et al., v. 3M Company, No. 2:23-cv-XXXX-RMG
