SIGN AND DATE. All sums payable under the Amended and Restated Executive Salary Continuation Agreement, by reason of my death shall be paid to the Primary Beneficiary(ies), if he or she survives me, and if no Primary Beneficiary(ies) shall survive me, then to the Secondary (Contingent) Beneficiary(ies). This beneficiary designation is valid until the participant notifies the bank in writing. Executive Date
SIGN AND DATE. This Beneficiary Designation Form is valid until the participant notifies the bank in writing.
SIGN AND DATE. On an annual basis, for the most recent year only, select the appropriate answer (yes or no) or write in the appropriate response indicating if you have been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.
SIGN AND DATE. WAIVER PART 8 OF 8
SIGN AND DATE. By signing below, the Tenant acknowledges receipt of a complete copy of this Rental Agreement with all blanks filled in.
SIGN AND DATE. The information on this form is true and correct to the best of my knowledge. I agree to participate in the Settlement. I authorize any dealership that serviced my vehicle to release records to the Settlement Administrator as needed to assist in the payment of my Claim. To the extent I am seeking reimbursement for a Qualifying Loss for which I do not have documentation, I attest as follows: ☐ Cash Payment for Repairs Performed at Hyundai or Kia Dealership: I hereby swear under penalty of perjury under the laws of the United States that I had repairs performed at an authorized Hyundai or Kia dealership (name of dealership) and paid $ in cash but I do not have a cash payment receipt from the dealership showing payment. ☐ Cash Payment in General: I hereby swear under penalty of perjury under the laws of the United States that I paid for (description of reason for payment) and paid $ in cash but I do not have a cash payment receipt showing payment. Along with this attestation, I am submitting a valid corresponding final invoice or repair order and proof of withdrawal of cash from a bank or credit union. ☐ Unrecovered Class Vehicle: I hereby swear under penalty of perjury under the laws of the United States that I experienced a Qualifying Theft of my Class Vehicle on _ (Date) and as of today, I still have not recovered my Class Vehicle. (Note: In the event a Class Vehicle is recovered following the submission of this Claim, but before payment is issued from the Common Fund, you must notify the Settlement Administrator of the recovery and the condition of the recovered Class Vehicle.) Signature: Date: ‐ ‐ MM DD YYYY
SIGN AND DATE. An assessment of suitability of the course
SIGN AND DATE. I have read and reviewed the information on both sides of this Application and Account Agreement. By signing below, I indicate my acceptance and consent to the terms and conditions of this Application and Account Agreement. Signature: Date:
SIGN AND DATE. I have read and reviewed the information on both sides of this Application and Agreement. By signing below, I indicate my acceptance and consent to the terms and conditions of this Application and Agreement. Please read this Application and Agreement carefully. By signing on the reverse side, or using the 405 Express Lanes or your FasTrak® Transponder, you agree to the following terms: P.O. Box 2177, Costa Mesa, CA 92628 562-740-4405 • xxx.000XxxxxxxXxxxx.xxx
SIGN AND DATE. I have read the above and agree to abide by the payment and terms and conditions as outlined. I understand that this form confirms my reservation. I accept that from now on charges will be imposed for cancelled reservations.
