:@0.120984:0.032497:0.125175:0.032497:0.125175:0.019384:0.120984:0.019384:0.004191
 :@0.120984:0.048461:0.125175:0.048461:0.125175:0.035348:0.120984:0.035348:0.004191
YOUR DETAILS* :@0.120984:0.064424:0.245507:0.064424:0.245507:0.051311:0.120984:0.051311:0.009643:0.012536:0.012110:0.010441:0.004228:0.011498:0.009050:0.009087:0.011238:0.004896:0.007844:0.008691:0.009071:0.004191
Title:  Mr / Mrs / Miss / Ms / Dr          :@0.120984:0.080958:0.412292:0.080958:0.412292:0.067845:0.120984:0.067845:0.009031:0.004265:0.006212:0.004265:0.009235:0.004886:0.004191:0.018378:0.015911:0.006472:0.004006:0.007232:0.004191:0.015948:0.006250:0.007251:0.004191:0.007103:0.004191:0.015948:0.004265:0.007028:0.007251:0.004191:0.007103:0.004191:0.015763:0.007251:0.004191:0.007103:0.004191:0.011516:0.006250:0.004191:0.004265:0.004191:0.004080:0.004191:0.004265:0.004191:0.004265:0.004024:0.004191
delete as applicable:@0.412501:0.080958:0.560704:0.080958:0.560704:0.067845:0.412501:0.067845:0.009476:0.008864:0.004265:0.008864:0.006212:0.008679:0.004191:0.009532:0.007214:0.004260:0.009476:0.009476:0.009476:0.004265:0.004210:0.007715:0.009421:0.009476:0.004265:0.008864
 :@0.560656:0.080958:0.564847:0.080958:0.564847:0.067845:0.560656:0.067845:0.004191
 :@0.120984:0.096921:0.125175:0.096921:0.125175:0.083808:0.120984:0.083808:0.004191
Surname __________________________________ Forename _______________________________ :@0.120984:0.112909:0.879586:0.112909:0.879586:0.099796:0.120984:0.099796:0.008512:0.009625:0.006472:0.009662:0.008883:0.014891:0.009235:0.004247:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.004191:0.008308:0.009866:0.006472:0.009235:0.009736:0.008623:0.014891:0.009235:0.004061:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009658:0.004191
 :@0.120984:0.128872:0.125175:0.128872:0.125175:0.115759:0.120984:0.115759:0.004191
Address ___________________________________________________________________________  :@0.120984:0.144836:0.883819:0.144836:0.883819:0.131723:0.120984:0.131723:0.010737:0.009625:0.009680:0.006472:0.009235:0.007251:0.007251:0.004247:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.004619:0.004191
 :@0.120984:0.160799:0.125175:0.160799:0.125175:0.147686:0.120984:0.147686:0.004191
__________________________________________Postcode________________________________ :@0.120984:0.176620:0.875554:0.176620:0.875554:0.163507:0.120984:0.163507:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009505:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009377:0.009476:0.009680:0.007251:0.006212:0.007881:0.009866:0.009476:0.009329:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009312:0.004191
 :@0.120984:0.192584:0.125175:0.192584:0.125175:0.179471:0.120984:0.179471:0.004191
Email _____________________________________________________________________________ :@0.120984:0.208547:0.879183:0.208547:0.879183:0.195434:0.120984:0.195434:0.009071:0.014891:0.008883:0.004265:0.004191:0.004024:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009697:0.004191
 :@0.120984:0.224511:0.125175:0.224511:0.125175:0.211398:0.120984:0.211398:0.004191
Contact telephone number ___________________________________________________________ :@0.120984:0.240474:0.875756:0.240474:0.875756:0.227361:0.120984:0.227361:0.009884:0.009847:0.009680:0.006212:0.008883:0.007678:0.006212:0.004247:0.006212:0.009291:0.004024:0.009235:0.009736:0.009643:0.009866:0.009680:0.009068:0.004191:0.009736:0.009662:0.014891:0.009680:0.009235:0.006287:0.004191:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009105:0.009235:0.009291:0.009068:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009685:0.004191
 :@0.120984:0.256438:0.125175:0.256438:0.125175:0.243325:0.120984:0.243325:0.004191
 :@0.120984:0.272401:0.125175:0.272401:0.125175:0.259288:0.120984:0.259288:0.004191
 :@0.120984:0.288935:0.125175:0.288935:0.125175:0.275822:0.120984:0.275822:0.004191
 :@0.120984:0.307321:0.125175:0.307321:0.125175:0.294208:0.120984:0.294208:0.004191
For Personal Injury claims only :@0.120984:0.325601:0.359647:0.325601:0.359647:0.312488:0.120984:0.312488:0.008512:0.009829:0.006639:0.004191:0.009866:0.009328:0.006639:0.007436:0.009884:0.009884:0.009068:0.004618:0.004024:0.005026:0.009884:0.004822:0.009884:0.006454:0.008846:0.004024:0.007844:0.004618:0.008864:0.004618:0.015274:0.007251:0.004024:0.009884:0.009884:0.004618:0.008735:0.004191
 :@0.120984:0.342135:0.125175:0.342135:0.125175:0.329022:0.120984:0.329022:0.004191
Date of birth:  _____/_____/_____ :@0.120984:0.372351:0.398550:0.372351:0.398550:0.359238:0.120984:0.359238:0.011479:0.008883:0.006212:0.009087:0.004191:0.009903:0.005434:0.004191:0.009753:0.004265:0.006472:0.006212:0.009662:0.004834:0.004191:0.016168:0.009235:0.009291:0.009235:0.009105:0.009235:0.007084:0.009235:0.009291:0.009068:0.009235:0.009105:0.007232:0.009235:0.009105:0.009235:0.009291:0.009219:0.004191
 :@0.423386:0.372351:0.427577:0.372351:0.427577:0.359238:0.423386:0.359238:0.004191
  :@0.483857:0.372351:0.492281:0.372351:0.492281:0.359238:0.483857:0.359238:0.004233:0.004191
National insurance number: :@0.120984:0.402568:0.334803:0.402568:0.334803:0.389455:0.120984:0.389455:0.011887:0.008883:0.006212:0.004265:0.009847:0.009680:0.008883:0.004265:0.004191:0.004265:0.009643:0.007251:0.009736:0.006398:0.008883:0.009662:0.007844:0.009087:0.004191:0.009736:0.009662:0.014891:0.009680:0.009235:0.006287:0.005062:0.004191
 :@0.120984:0.417391:0.121166:0.417391:0.121166:0.416821:0.120984:0.416821:0.000182
 :@0.359890:0.407984:0.364082:0.407984:0.364082:0.394871:0.359890:0.394871:0.004191
 :@0.442938:0.407984:0.447129:0.407984:0.447129:0.394871:0.442938:0.394871:0.004191
 :@0.538282:0.407984:0.542473:0.407984:0.542473:0.394871:0.538282:0.394871:0.004191
 :@0.633458:0.407984:0.637649:0.407984:0.637649:0.394871:0.633458:0.394871:0.004191
 :@0.728801:0.407984:0.732992:0.407984:0.732992:0.394871:0.728801:0.394871:0.004191
 :@0.120984:0.435920:0.125175:0.435920:0.125175:0.422807:0.120984:0.422807:0.004191
Any other relevant comments that you wish to make :@0.120984:0.466137:0.529975:0.466137:0.529975:0.453024:0.120984:0.453024:0.011238:0.009959:0.008790:0.004265:0.009884:0.006435:0.009884:0.009272:0.006639:0.004024:0.006639:0.009272:0.004618:0.009068:0.008846:0.009068:0.009884:0.006435:0.004228:0.007844:0.009884:0.014910:0.015077:0.009105:0.009884:0.006435:0.007455:0.004191:0.006472:0.009884:0.009068:0.006435:0.004043:0.008846:0.009884:0.009884:0.004191:0.013742:0.004618:0.007436:0.009884:0.004191:0.006472:0.009884:0.004024:0.015077:0.009161:0.008827:0.009540:0.004191
 :@0.120984:0.482671:0.125175:0.482671:0.125175:0.469558:0.120984:0.469558:0.004191
 :@0.120984:0.588025:0.125175:0.588025:0.125175:0.574912:0.120984:0.574912:0.004191
DECLARATION* :@0.120984:0.618242:0.244096:0.618242:0.244096:0.605129:0.120984:0.605129:0.011683:0.009050:0.009884:0.007659:0.011238:0.010515:0.011090:0.009068:0.005026:0.012536:0.012101:0.009071:0.004191
In line with Part 6 of the Local Audit and Accountability Act 2014 , the Council participates in the :@0.120984:0.634775:0.846187:0.634775:0.846187:0.621662:0.120984:0.621662:0.004673:0.009643:0.004191:0.004265:0.004265:0.009662:0.009235:0.004247:0.013259:0.004265:0.006212:0.009736:0.004022:0.009662:0.008883:0.006472:0.006009:0.004191:0.009495:0.004024:0.009866:0.005656:0.004024:0.006212:0.009736:0.009235:0.004043:0.007844:0.009680:0.007844:0.008883:0.004265:0.004191:0.010737:0.009643:0.009680:0.004265:0.006212:0.004191:0.008883:0.009736:0.009643:0.004191:0.010737:0.007844:0.007659:0.009866:0.009680:0.009680:0.006212:0.008883:0.009736:0.004191:0.004265:0.004210:0.006045:0.008456:0.004191:0.010737:0.007844:0.006045:0.004191:0.009309:0.009458:0.009272:0.009458:0.004430:0.004636:0.004024:0.006212:0.009736:0.009235:0.004191:0.009736:0.009866:0.009680:0.009680:0.007844:0.004265:0.004265:0.004191:0.009662:0.008883:0.006231:0.006212:0.004265:0.007844:0.004265:0.009662:0.008883:0.006212:0.009272:0.007251:0.004191:0.004265:0.009495:0.004191:0.006268:0.009680:0.009235:0.004191
National Fraud Initiative. The information you provide will be held on computerised systems and/or :@0.120984:0.650739:0.872388:0.650739:0.872388:0.637626:0.120984:0.637626:0.011887:0.008883:0.006212:0.004265:0.009847:0.009680:0.008883:0.004265:0.004191:0.008512:0.006398:0.008883:0.009662:0.009692:0.004233:0.004673:0.009643:0.004265:0.006212:0.004265:0.008883:0.006212:0.004024:0.008456:0.009235:0.004673:0.004024:0.008864:0.009680:0.009235:0.004247:0.004265:0.009643:0.005656:0.009847:0.006250:0.014891:0.008883:0.006212:0.004061:0.009866:0.009680:0.004191:0.008308:0.009866:0.009680:0.004191:0.009736:0.006231:0.009866:0.008456:0.004265:0.009643:0.009068:0.004191:0.013334:0.004265:0.004210:0.004265:0.004191:0.009736:0.009235:0.004191:0.009695:0.009272:0.004265:0.009643:0.004191:0.009903:0.009680:0.004024:0.007844:0.009699:0.014891:0.009680:0.009680:0.006212:0.009105:0.006472:0.004265:0.007010:0.009235:0.009736:0.004191:0.007251:0.008475:0.007047:0.006212:0.009105:0.014891:0.007251:0.004191:0.008883:0.009736:0.009439:0.007232:0.009866:0.006472:0.004191
papers files, and used for cross-system and cross authority comparison for the prevention and :@0.120984:0.666702:0.831141:0.666702:0.831141:0.653589:0.120984:0.653589:0.009680:0.008883:0.009662:0.009235:0.006472:0.007251:0.004228:0.005656:0.004265:0.004191:0.009235:0.007251:0.004636:0.004080:0.008883:0.009662:0.009680:0.004191:0.009736:0.007251:0.009235:0.009736:0.004191:0.005452:0.009866:0.006472:0.004191:0.007678:0.006472:0.009829:0.007251:0.007350:0.005644:0.007047:0.008456:0.007251:0.006212:0.009105:0.014891:0.004024:0.008883:0.009662:0.009680:0.004191:0.007881:0.006472:0.009662:0.007251:0.007251:0.004191:0.008883:0.009736:0.006212:0.009495:0.009866:0.006472:0.004265:0.006212:0.008252:0.004191:0.007696:0.009866:0.014891:0.009680:0.008883:0.006472:0.004191:0.007047:0.010028:0.009680:0.004191:0.005489:0.009866:0.006472:0.004006:0.006212:0.009736:0.009235:0.004191:0.009736:0.006250:0.009235:0.008493:0.009235:0.009736:0.006212:0.004043:0.009866:0.009680:0.004191:0.008883:0.009736:0.009643:0.004191
detection of fraud. :@0.120984:0.682666:0.265865:0.682666:0.265865:0.669553:0.120984:0.669553:0.009680:0.009235:0.006268:0.009235:0.007844:0.006287:0.004024:0.009866:0.009680:0.004024:0.009866:0.005656:0.004191:0.005656:0.006472:0.008883:0.009662:0.009680:0.004480:0.004191
 :@0.120984:0.698629:0.125175:0.698629:0.125175:0.685516:0.120984:0.685516:0.004191
In addition, we will pass your records to our Insurers who will also pass the information to the Claims :@0.120984:0.714593:0.882668:0.714593:0.882668:0.701480:0.120984:0.701480:0.004673:0.009643:0.004191:0.008883:0.009736:0.009643:0.004265:0.006212:0.004265:0.009829:0.009680:0.004636:0.004191:0.013148:0.009235:0.004247:0.013259:0.004265:0.004265:0.004006:0.004191:0.009736:0.008883:0.007251:0.007251:0.004006:0.008456:0.009680:0.009680:0.006472:0.004191:0.006472:0.009235:0.007844:0.009773:0.006398:0.009680:0.007251:0.004191:0.006101:0.009866:0.004024:0.009866:0.009680:0.006472:0.004191:0.004673:0.009662:0.007251:0.009736:0.006398:0.009235:0.006472:0.007251:0.004061:0.013259:0.009736:0.009847:0.004024:0.013259:0.004265:0.004265:0.004265:0.004191:0.008883:0.004210:0.007047:0.009866:0.004191:0.009736:0.008883:0.007251:0.007251:0.004006:0.006212:0.009736:0.009235:0.004191:0.004265:0.009736:0.005396:0.009866:0.006250:0.014891:0.008883:0.006212:0.004061:0.009866:0.009680:0.004191:0.006083:0.009866:0.004191:0.006268:0.009476:0.009235:0.004247:0.009884:0.004265:0.008883:0.003987:0.014891:0.007251:0.004191
& Underwriting Exchange Register; the Motor Insurance Anti-Fraud & Theft register; and other :@0.120984:0.730592:0.835332:0.730592:0.835332:0.717479:0.120984:0.717479:0.012647:0.004265:0.011906:0.009662:0.009680:0.009235:0.006472:0.013111:0.006472:0.004265:0.006212:0.004265:0.009625:0.008660:0.004191:0.009087:0.008030:0.007844:0.009736:0.008883:0.009643:0.008660:0.009068:0.004191:0.009921:0.009235:0.008734:0.004210:0.007251:0.006212:0.009291:0.006250:0.005026:0.004191:0.006268:0.009680:0.009068:0.004191:0.015763:0.009866:0.006045:0.009866:0.006472:0.004191:0.004673:0.009662:0.007251:0.009736:0.006398:0.008883:0.009662:0.007659:0.009235:0.004247:0.010737:0.009625:0.006212:0.004509:0.005644:0.008512:0.006398:0.008883:0.009662:0.009680:0.004191:0.012722:0.004024:0.009031:0.009736:0.009235:0.005656:0.006212:0.004080:0.006472:0.009235:0.008734:0.004173:0.007251:0.006045:0.009235:0.006472:0.005044:0.004191:0.008883:0.009736:0.009643:0.004024:0.009866:0.006212:0.009736:0.009235:0.006268:0.004191
similar agencies and bodies. We may also share your information with our claims handlers, legal :@0.120984:0.746413:0.845774:0.746413:0.845774:0.733300:0.120984:0.733300:0.007251:0.004265:0.014873:0.004265:0.004210:0.008883:0.006472:0.004191:0.008883:0.008456:0.009235:0.009736:0.007842:0.004265:0.009235:0.007251:0.004191:0.008883:0.009736:0.009662:0.004191:0.009513:0.009866:0.009680:0.004265:0.009235:0.007065:0.004673:0.004191:0.016505:0.009291:0.004024:0.014891:0.008660:0.008456:0.004191:0.008883:0.004265:0.007047:0.009866:0.004191:0.007251:0.009736:0.008883:0.006472:0.009031:0.004191:0.008308:0.009866:0.009680:0.006472:0.004191:0.004043:0.009680:0.005656:0.009847:0.006472:0.014873:0.008660:0.006212:0.004265:0.009866:0.009680:0.004024:0.013259:0.004265:0.006212:0.009736:0.004024:0.009866:0.009680:0.006472:0.004432:0.007844:0.004265:0.008883:0.004006:0.014891:0.007047:0.004191:0.009736:0.008883:0.009643:0.009680:0.004265:0.009235:0.006472:0.007251:0.004636:0.004297:0.004265:0.009235:0.008679:0.008883:0.004265:0.004191
representatives, contractors or outside bodies who may be involved with the investigation of your :@0.120984:0.762376:0.861284:0.762376:0.861284:0.749264:0.120984:0.749264:0.006472:0.009235:0.009736:0.006398:0.009235:0.007251:0.009291:0.009680:0.006212:0.008698:0.006212:0.004265:0.008271:0.009235:0.007251:0.004636:0.004300:0.007660:0.009866:0.009680:0.006212:0.006472:0.008679:0.007844:0.006064:0.009866:0.006250:0.007251:0.004191:0.009903:0.006472:0.004006:0.009866:0.009680:0.006212:0.007251:0.004265:0.009476:0.009235:0.004247:0.009680:0.009866:0.009680:0.004265:0.009031:0.007251:0.004191:0.013334:0.009476:0.009866:0.004024:0.014706:0.008883:0.008401:0.004265:0.009680:0.009235:0.004247:0.004265:0.009439:0.008456:0.009866:0.004024:0.008456:0.009235:0.009736:0.004006:0.013259:0.004265:0.006212:0.009736:0.004024:0.006212:0.009736:0.009235:0.004191:0.004265:0.009736:0.008234:0.009235:0.007251:0.006268:0.004265:0.008642:0.008883:0.006212:0.004061:0.009866:0.009680:0.004191:0.009903:0.005434:0.004191:0.008308:0.009866:0.009680:0.006472:0.004191
claim. :@0.120984:0.778340:0.169722:0.778340:0.169722:0.765227:0.120984:0.765227:0.007844:0.004265:0.008883:0.004210:0.014891:0.004454:0.004191
 :@0.120984:0.794303:0.125175:0.794303:0.125175:0.781191:0.120984:0.781191:0.004191
I declare that the details I have provided in this form are true to the best of my knowledge and :@0.120984:0.810267:0.850808:0.810267:0.850808:0.797154:0.120984:0.797154:0.005026:0.004191:0.009959:0.009235:0.007659:0.004618:0.009068:0.006639:0.009272:0.004191:0.006472:0.009884:0.009068:0.006435:0.004228:0.006435:0.009884:0.009272:0.004191:0.009959:0.009235:0.006435:0.009087:0.004432:0.004618:0.007251:0.004191:0.005063:0.004024:0.009884:0.009068:0.008846:0.009272:0.004191:0.009959:0.006583:0.009903:0.008846:0.004618:0.009884:0.009272:0.009884:0.004024:0.004618:0.009884:0.004191:0.006472:0.009884:0.004432:0.007436:0.004191:0.005860:0.009903:0.006639:0.014910:0.004191:0.009161:0.006583:0.009328:0.004191:0.006435:0.006658:0.009884:0.009272:0.004191:0.006472:0.010248:0.004031:0.006435:0.009884:0.009272:0.004191:0.009959:0.009235:0.007436:0.006435:0.004228:0.009884:0.005860:0.004191:0.014947:0.008846:0.004024:0.008901:0.009847:0.009884:0.013890:0.004618:0.009272:0.009884:0.008846:0.009272:0.004191:0.009161:0.009829:0.009884:0.004191
belief. I understand that the information I provide may be shared with other bodies and agencies :@0.120984:0.826231:0.869410:0.826231:0.869410:0.813118:0.120984:0.813118:0.009884:0.009272:0.004618:0.004618:0.009272:0.005860:0.005007:0.004072:0.005026:0.004191:0.009959:0.009829:0.009884:0.009272:0.006639:0.007436:0.006435:0.009087:0.009884:0.009884:0.004191:0.006472:0.009884:0.009068:0.006435:0.004043:0.006250:0.009884:0.009272:0.004329:0.004618:0.009884:0.005860:0.009866:0.006639:0.015077:0.009161:0.006435:0.004562:0.009921:0.009884:0.004024:0.005026:0.004191:0.009959:0.006583:0.009903:0.008660:0.004618:0.009884:0.009272:0.004024:0.015077:0.009161:0.008790:0.004247:0.009884:0.009272:0.004191:0.007473:0.009884:0.009068:0.006639:0.009272:0.009884:0.004024:0.013890:0.004432:0.006435:0.009884:0.004191:0.009921:0.006435:0.009884:0.009272:0.006639:0.004024:0.009884:0.009884:0.009884:0.004618:0.009272:0.007436:0.004191:0.009161:0.009829:0.009884:0.004191:0.009161:0.008790:0.009328:0.009847:0.007844:0.004618:0.009272:0.007251:0.004191
as permitted by law and also for the purpose of detecting and preventing fraud. I understand that :@0.120984:0.842194:0.874360:0.842194:0.874360:0.829081:0.120984:0.829081:0.009068:0.007436:0.004191:0.009959:0.009235:0.006639:0.015077:0.004469:0.006435:0.006435:0.009328:0.009847:0.004191:0.009959:0.008790:0.004080:0.004618:0.009068:0.013705:0.004191:0.009161:0.009829:0.009884:0.004191:0.009161:0.004395:0.007436:0.009884:0.004191:0.005860:0.009903:0.006639:0.004191:0.006472:0.009884:0.009272:0.004191:0.009959:0.009829:0.006639:0.009884:0.009884:0.007436:0.009272:0.004191:0.009921:0.005860:0.004191:0.009959:0.009217:0.006435:0.009087:0.007844:0.006435:0.004636:0.009680:0.008846:0.004191:0.009161:0.009829:0.009884:0.004191:0.009959:0.006583:0.009328:0.008827:0.009272:0.009884:0.006250:0.004618:0.009884:0.008846:0.004191:0.005693:0.006639:0.009068:0.009884:0.009884:0.005026:0.004191:0.004877:0.004191:0.009959:0.009829:0.009884:0.009272:0.006639:0.007436:0.006435:0.009087:0.009884:0.009884:0.004191:0.006472:0.009884:0.009068:0.006435:0.004191
action will be taken against me if I provide information that is untrue. :@0.120984:0.858158:0.659418:0.858158:0.659418:0.845045:0.120984:0.845045:0.009068:0.007844:0.006435:0.004636:0.009884:0.009884:0.004024:0.013890:0.004432:0.004618:0.004618:0.004191:0.009959:0.009235:0.004191:0.006472:0.009068:0.008901:0.009235:0.009884:0.004191:0.009161:0.008790:0.008901:0.004618:0.009884:0.007251:0.006435:0.004228:0.015077:0.009496:0.004031:0.004618:0.005860:0.004191:0.004859:0.004191:0.009959:0.006583:0.009903:0.008660:0.004618:0.009884:0.009272:0.004191:0.004655:0.009884:0.005860:0.009866:0.006639:0.015077:0.009161:0.006194:0.004432:0.009884:0.009884:0.004191:0.006472:0.009884:0.009068:0.006435:0.004228:0.004618:0.007436:0.004191:0.009959:0.009829:0.006435:0.006658:0.009884:0.009068:0.005027:0.004191
 :@0.120984:0.874121:0.125175:0.874121:0.125175:0.861008:0.120984:0.861008:0.004191
Signature*_______________________________Date*_____/______/______ :@0.120984:0.890080:0.711223:0.890080:0.711223:0.876967:0.120984:0.876967:0.008846:0.004432:0.008846:0.009884:0.009068:0.006435:0.009884:0.006639:0.009331:0.009272:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.009068:0.009235:0.009291:0.011683:0.009087:0.006435:0.009338:0.009272:0.009235:0.009291:0.009068:0.009235:0.009105:0.008048:0.009235:0.009105:0.009235:0.009291:0.009068:0.009235:0.007900:0.009235:0.009291:0.009068:0.009235:0.009291:0.009203:0.004191
 :@0.120984:0.906756:0.125175:0.906756:0.125175:0.893643:0.120984:0.893643:0.004191