DECLARATION UNDER PENALTY OF PERJURY. I understand that I am required to permit the City of Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices for the purpose of investigation or to ascertain compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply with LAAC Section 10.8.2,1 et seq,. Equal Benefits Ordinance may he deemed a material breach of any City contract by the Awarding Authority, The Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved, The City may also pursue any and all other remedies at iaw or in . equity for any breach, The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the LAAC Section 10,40,. et seq., Contractor Responsibility Ordinance, Company Name will comply with the Equal Benefits Ordinance requirements as indicated above prior to executing a contract with the City of Los Angeles and will comply for the entire duration of the contract(s). I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Executed this day of j in the year 20_ .> aL (City) (State) Signature . Mailing Address Name of Signatory (please print) City, State, Zip Code Title Form OCC/EBO-Affidavit (Rev 6/21/12) EIN/T1N
DECLARATION UNDER PENALTY OF PERJURY. Each person submitting and/or signing an invoice on behalf of Contractor declares under penalty of perjury under California laws, and certifies and attests that: (A) he/she has thoroughly reviewed the claim for payment and know its content; (B) the invoice and supporting information are true, accurate, and complete, and reflect amounts due and Services that Contractor has completed in accordance with this Master Contract and the applicable Site Contract or Tutoring Services Order, and the correct amount for the Services; (C) Contractor has complied and is in compliance with all obligations required of Contractor under this Master Contract and the applicable Site Contract or Tutoring Services Order; and (D) he/she is familiar with Penal Code section 72 pertaining to false claims, and knows and understands that submission and/or certification of a false claim may lead to fines, imprisonment, and/or other legal consequences.
DECLARATION UNDER PENALTY OF PERJURY. Each person submitting and/or signing an invoice on behalf of Contractor declares under penalty of perjury under California laws, and certifies and attests that: (A) he/she has thoroughly reviewed the claim for payment and knows its content; (B) the invoice and supporting information are true, accurate, and complete, and reflect amounts due and Services that Contractor has completed in accordance with the Contract and the correct amount for those Services;
DECLARATION UNDER PENALTY OF PERJURY. Each person signing below acknowledges and understands that this form is an official document sanctioned by the Court that presides over the legal action entitled In Re Sulzer Hip Prosthesis and Knee Prosthesis Product Liability Litigation. Submitting this Claim Form to the Claims Administrator is equivalent to filing it with the Court. After reviewing the information that has been provided on this form, including information, if applicable, that was supplied by a Board-Certified physician and/or an attorney, each person signing this form declares under penalty of perjury that all of the information provided in this form is true and correct to the best of that person's knowledge and belief. / / --------------------------------------------------- ------------------- (Signature of APR) (Date - MM/DD/YYYY) OR / / --------------------------------------------------- ------------------- (Signature of Each Representative Claimant, if any) (Date - MM/DD/YYYY) Mail this Claim Form and all attachments to: Claims Administrator Sulzer Settlement Trust P.O. Box 94558 Cleveland, Ohio 44101-4558 XXXXXX XXXX - 00 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND OTHER HEALTH INFORMATION I hereby authorize the use or disclosure of my individually identifiable health information and medical records as described below. I understand that this authorization is voluntary. I understand that because the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations, but it will be subject to the confidentiality provisions of the Settlement Agreement. INFORMATION AUTHORIZED FOR RELEASE: I authorize the release of the following records/recordings to the Sulzer Settlement Trust: any medical records that pertain or relate to the diagnosis, care or treatment of any disease, condition or procedure related to or arising from any implantation in the Patient/Affected Product Recipient of a hip or knee prosthesis(es) including information about the undersigned Affected Product Recipient or Patient, his/her hip or knee prosthesis(es), the hospital(s) where and surgeon(s) who made, provided, gave or performed any diagnosis, care treatment, or procedure, the manufacturer, product and lot numbers of any hip or knee prostheses, any surgery(ies) associated with the hip or knee prosthesis(es), the date(s) and nature of any medical treatment associated with the implant(s) of the hip ...
DECLARATION UNDER PENALTY OF PERJURY. When the Licensee signs this Agreement, such signature shall also be deemed to be a Declaration Under Penalty of Perjury that the averments in this Paragraph L and the evidence provided under said Paragraph is offered to be true and correct to the best of Licensee’s knowledge under the laws of the State where the Licensee is domiciled and has the Licensee’s Business Address.
DECLARATION UNDER PENALTY OF PERJURY. I understand that I am required to permit the City of Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices for the purpose of investigation or to ascertain compliance with the Equal Benefits Ordinance. I will notify the City’s Designated Administrative Agency if any changes are made that will affect our compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply with LAAC Section 10.8.2.1 et seq., Equal Benefits Ordinance may be deemed a material breach of any City contract by the Awarding Authority. The Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved. The City may also pursue any and all other remedies at law or in equity for any breach. The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the LAAC Section 10.40, et seq., Contractor Responsibility Ordinance. will comply with the Equal Benefits Ordinance requirements Company Name as indicated above prior to executing a contract with the City of Los Angeles and will comply for the entire duration of the contract(s). I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Executed this day of , in the year 20 , at , (City) (State) Signature Mailing Address Name of Signatory (please print) City, State, Zip Code
DECLARATION UNDER PENALTY OF PERJURY. I understand that I am required to permit the City of Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices for the purpose of investigation or to ascertain compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply with LAAC Section 10.8.2.1 et seq., Equal Benefits Ordinance may be deemed a material breach of any City contract by the Awarding Authority. The Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved. The City may also pursue any and all other remedies at law or in equity for any breach. The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the LAAC Section 10.40, et seq., Contractor Responsibility Ordinance.
DECLARATION UNDER PENALTY OF PERJURY. I understand that it is a federal offense (18 U.S. Code §1001) and state offense (18 Pa.C.S.A.
DECLARATION UNDER PENALTY OF PERJURY. Each person submitting and/or signing an invoice on behalf of Contractor declares under penalty of perjury under California laws, and certifies and attests that: (A) he/she has thoroughly reviewed the claim for payment and knows its content; (B) the invoice and supporting information are true, accurate, and complete, and reflect amounts due and Services that Contractor has completed in accordance with the Contract and the correct amount for those Services; (C) Contractor has complied and is in compliance with all obligations required of Contractor under the Contract; and (D) he/she is familiar with Penal Code section 72 pertaining to false claims, and knows and understands that submission and/or certification of a false claim may lead to fines, imprisonment, and/or other legal consequences.
DECLARATION UNDER PENALTY OF PERJURY. Each person signing below acknowledges and understands that this form is an official document sanctioned by the Court that presides over the legal action entitled In Re Sulzer Hip Prosthesis and Knee Prosthesis Product Liability Litigation. Submitting this Claim Form to the Claims Administrator is equivalent to filing it with the Court. After reviewing the information that has been provided on this form, including information, if applicable, that was supplied by a Board-Certified physician and/or an attorney, each person signing this form declares under penalty of perjury that the information provided in this form is true and correct to the best of that person's knowledge and belief. -------------------------------------------- ----------------- (Signature of Derivative Claimant) (Date MM/DD/YYYY) Mail this Claim Form and all attachments to: Claims Administrator Sulzer Settlement Trust P.O. Box 94558 Cleveland, Ohio 44101-4558 XXXXXX XXXX - 0 EXHIBIT G RED FORM ================================================================================ UNINSURED AFFECTED PRODUCT RECIPIENT BENEFITS CLAIM FORM THIS RED FORM IS TO BE USED ONLY BY A CLASS MEMBER REGISTERING FOR SETTLEMENT BENEFITS AS AN UNINSURED AFFECTED PRODUCT RECIPIENT ("UNINSURED APR") WHO HAS UNDERGONE AN AFFECTED PRODUCT REVISION SURGERY ("APRS"). THE COMPLETED FORM MUST BE POSTMARKED TO THE CLAIMS ADMINISTRATOR (C/O SULZER SETTLEMENT TRUST, P.O. BOX 94558, CLEVELAND, OHIO 44101-4558) NO LATER THAN (i) 180 DAYS XXXXX XXXXX XXXXX XXXXXXXX XX (XX) 000 XXYS AFTER AN APRS. AN ORANGE FORM MUST HAVE BEEN PREVIOUSLY SUBMITTED OR BE SIMULTANEOUSLY SUBMITTED FOR THE CLASS MEMBER TO QUALIFY TO RECEIVE BENEFITS. SEE THE FINAL NOTICE OF SETTLEMENT OF NATIONWIDE HIP PROSTHESIS AND KNEE PROSTHESIS PRODUCT LIABILITY CLASS ACTION LITIGATION ("FINAL NOTICE"), THE CLASS MEMBER AND ATTORNEY GUIDE, OR THE SETTLEMENT AGREEMENT FOR FURTHER INFORMATION. IF THERE IS ANY CONFLICT BETWEEN THE PROVISIONS OF THIS CLAIM FORM AND THE TERMS OF THE SETTLEMENT AGREEMENT, THE TERMS OF THE SETTLEMENT AGREEMENT CONTROL. All responses must be PRINTED or TYPED. By completing this Red Form, you(1) are registering for benefits under the Settlement Agreement. If you have retained an attorney regarding your claim, consult with your attorney about your options under the Settlement Agreement.
