Budget Information Funding Source Funding Year of Appropriation Budget List Number Amount EPIC 18-19 301.001F $500,000 EPIC 20-21 301.001H $500,000 R&D Program Area: EDMFO: EDMF TOTAL: $ 1,000,000 Explanation for “Other” selection Reimbursement Contract #: Federal Agreement #:
Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
Business Contact Information Each party consents to the other party using its Business Contact Information for contract management, payment processing, service offering, and business development purposes related to the Agreement and such other purposes as set out in the using party’s global data privacy policy (copies of which shall be made available upon request). For such purposes, and notwithstanding anything else set forth in the Agreement with respect to Client Personal Information in general, each party shall be considered a data controller with respect to the other party’s Business Contact Information and shall be entitled to transfer such information to any country where such party’s global organization operates. EXHIBIT A DEFINITIONS
- CLEC INFORMATION CLEC agrees to work with Qwest in good faith to promptly complete or update, as applicable, Qwest’s “New Customer Questionnaire” to the extent that CLEC has not already done so, and CLEC shall hold Qwest harmless for any damages to or claims from CLEC caused by CLEC’s failure to promptly complete or update the questionnaire.
Exchange Control Information Exchange control reporting is required for cash transactions exceeding AUD10,000 and for international fund transfers. If an Australian bank is assisting with the transaction, the bank will file the report on your behalf.
Factsheet Information General information entered into the higher education institutions’ profile and updated by the higher education institution. The general information about the institution is accessible to students. Calendar Incoming student nominations must reach the institution by: Autumn term [day/month] 04/30 Spring term [day/month] 09/30 Applications from incoming students must reach the institution by: Autumn term [day/month] 06/30 Spring term [day/month] 11/30 The institution will send its decision within 4 weeks, and no later than 5 weeks. Application procedure Information Contact email Contact phone Websites for information xxxxxxxx@xxxxxx.xxx.xx +000000000000 xxxxx://xxxxxxx.xxxxxx.xxx.xx/en Additional requirements Information Academic requirements ECTS completed Subject area (ISCED) EQF level Requirement Details Website Other Transcript xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/Erasmus--Europe/How-to-Apply/82 2 Other Copy of Passport xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/Erasmus--Europe/How-to-Apply/82 2 Other Learning Agreement xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/Erasmus--Europe/How-to-Apply/82 2 Inclusion and accessibility Information The institution will provide support to incoming mobile participants with special needs, according to the requirements of the Erasmus Charter for Higher Education. Information and assistance can be provided by the following contact points and information sources: Available infrastructure ad- justed for people with: Description of infras- tructure Contact details Website for information Infrastructure Not present xxxxx://xxxxxxx.xxxxxx.xxx.xx /en Available support services for people with: Description of infras- tructure Contact details Website for information Housing Information The institution will guide incoming mobile participants in finding accommodation, according to the requirements of the Erasmus Charter for Higher Education. Information and assistance can be provided by the following contact points and information sources: Contact email Contact phone Websites for information xxxxxxxx@xxxxxx.xxx.xx +000000000000 xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/16/Accom modation/474 Visa Information The institution will provide assistance, when required, in securing visas for incoming and outbound mobile partici- pants, according to the requirements of the Erasmus Charter for Higher Education. Information and assistance can be provided by the following contact points and information sources: Contact email Contact phone Websites for information xxxxxxxx@xxxxxx.xxx.xx +000000000000 xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/16/Visa-an d-Residence-Permit/472 Insurance Information The institution will provide assistance in obtaining insurance for incoming and outbound mobile participants, accord- ing to the requirements of the Erasmus Charter for Higher Education. The receiving institution will inform mobile par- ticipants of cases in which insurance cover is not automatically provided. Information and assistance can be provided by the following contact points and information sources: Contact email Contact phone Websites for information xxxxxxxx@xxxxxx.xxx.xx +000000000000 xxxxx://xxxxxxx.xxxxxx.xxx.xx/page/16/Healt h-Insurance/473 Additional Information Information on Contact email Contact phone Website for information A Transcript of Records will be issued by the institution no later than 4 weeks after the assessment period has finished. [It should normally not exceed five weeks according to the Erasmus Charter for Higher Education guidelines]
How Do I Get More Information? For more information, including the full Notice, Claim Forms and Settlement Agreement go to xxx.xxxxxxxxxxxxxxxxxxxx.xxx, contact the settlement administrator at 0-000-000-0000, or call Class Counsel at 1-866-354-3015. Exhibit E UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF FLORIDA Xxxxx v. AvMed, Inc., Case No. 10-cv-24513 If You Paid for or Received Insurance from AvMed, Inc. at Any Time Through December of 2009, You May Be Part of a Class Action Settlement. IMPORTANT: PLEASE READ THIS NOTICE CAREFULLY. THIS NOTICE RELATES TO THE PENDENCY OF A CLASS ACTION LAWSUIT AND, IF YOU ARE A MEMBER OF THE SETTLEMENT CLASSES, CONTAINS IMPORTANT INFORMATION ABOUT YOUR RIGHTS TO MAKE A CLAIM UNDER THE SETTLEMENT OR TO OBJECT TO THE SETTLEMENT (A federal court authorized this notice. It is not a solicitation from a lawyer.) Your legal rights are affected whether or not you act. Please read this notice carefully. YOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT SUBMIT A CLAIM FORM This is the only way to receive a payment. EXCLUDE YOURSELF You will receive no benefits, but you will retain any rights you currently have to xxx the Defendant about the claims in this case. OBJECT Write to the Court explaining why you don’t like the Settlement. GO TO THE HEARING Ask to speak in Court about your opinion of the Settlement. DO NOTHING You won’t get a share of the Settlement benefits and will give up your rights to xxx the Defendant about the claims in this case. These rights and options – and the deadlines to exercise them – are explained in this Notice. QUESTIONS? CALL 0-000-000-0000 TOLL FREE, OR VISIT XXX.XXXXXXXXXXXXXXXXXXXX.XXX PARA UNA NOTIFICACIÓN EN ESPAÑOL, LLAMAR O VISITAR NUESTRO WEBSITE BASIC INFORMATION
Alert Information As Alerts delivered via SMS, email and push notifications are not encrypted, we will never include your passcode or full account number. You acknowledge and agree that Alerts may not be encrypted and may include your name and some information about your accounts, and anyone with access to your Alerts will be able to view the contents of these messages.
Confidential System Information HHSC prohibits the unauthorized disclosure of Other Confidential Information. Grantee and all Grantee Agents will not disclose or use any Other Confidential Information in any manner except as is necessary for the Project or the proper discharge of obligations and securing of rights under the Contract. Grantee will have a system in effect to protect Other Confidential Information. Any disclosure or transfer of Other Confidential Information by Xxxxxxx, including information requested to do so by HHSC, will be in accordance with the Contract. If Grantee receives a request for Other Confidential Information, Xxxxxxx will immediately notify HHSC of the request, and will make reasonable efforts to protect the Other Confidential Information from disclosure until further instructed by the HHSC. Grantee will notify HHSC promptly of any unauthorized possession, use, knowledge, or attempt thereof, of any Other Confidential Information by any person or entity that may become known to Grantee. Grantee will furnish to HHSC all known details of the unauthorized possession, use, or knowledge, or attempt thereof, and use reasonable efforts to assist HHSC in investigating or preventing the reoccurrence of any unauthorized possession, use, or knowledge, or attempt thereof, of Other Confidential Information. HHSC will have the right to recover from Grantee all damages and liabilities caused by or arising from Grantee or Grantee Agents’ failure to protect HHSC’s Confidential Information as required by this section. IN COORDINATION WITH THE INDEMNITY PROVISIONS CONTAINED IN THE UTC, Xxxxxxx WILL INDEMNIFY AND HOLD HARMLESS HHSC FROM ALL DAMAGES, COSTS, LIABILITIES, AND EXPENSES (INCLUDING WITHOUT LIMITATION REASONABLE ATTORNEYS’ FEES AND COSTS) CAUSED BY OR ARISING FROM Grantee OR Grantee AGENTS FAILURE TO PROTECT OTHER CONFIDENTIAL INFORMATION. Grantee WILL FULFILL THIS PROVISION WITH COUNSEL APPROVED BY HHSC.
Service Information Service Visit Date Mode of service Face-to face, telephone, etc. Responsibility for payment Used to exclude federal govt., WCB, etc. Main and secondary diagnoses ICD10-CA codes Main and other interventions and attributes CCI procedure codes and attributes Type of Anesthetic Identifies the type used for interventions (general, spinal, local, etc.) Provider types NACRS code assigned to provider type (MD, Dentist, RN, etc.) Doctor name and identifier Physician specific information Admit via Ambulance Used if a Client is brought to the service delivery site by ambulance Institution from and institution to Used when a Client is transferred from or to another acute care facility Visit disposition Discharged, admitted, left without being seen, etc. Schedule “D” Appendix 2 Additional Elements Required for Data Management (XXX) Client Identifying Information Province Client‟s Home Province AB, BC, SK, MB, NL, PE, NS, NB, QC, ON, NT, YT, NU, US, OC (Other Country), NR (Unsp. Non-resident) Service Information Facility Code AHS provided code that indicates service being provided. Facility Fee Dollar value of service being provided Alberta Health Physician Fee Billing Code Alberta Health Physician Service Fee code that further defines facility code Regional standard format and submission method remains as is via excel file and email. NOTE: Submission method may be adjusted in accordance with security standards of AHS. Schedule “D” Appendix 3
