Request for Qualifications Financial Examination Support Services

RFQ 2013-001

Issued By:

Pennsylvania Insurance Department

Bureau of Administration

1326 Strawberry Square

Harrisburg, PA 17120

Contact: Peter J Salvatore

(717) 787-4429

Introduction:

The Pennsylvania Insurance Department (“Department”) is compiling a list of qualified vendors

to perform various services related to the financial examination function of the Department. The

Department will qualify vendors to support full-scope and limited-scope financial examinations

by providing field examiner, Information Technology (“IT”) specialist and/or actuarial and other

specialist services. The Department will evaluate vendors that provide any or all of the needed

services for inclusion on the list of qualified vendors.

Issuing Office:

This Request for Qualifications (“RFQ”) is issued by the Commonwealth of Pennsylvania

through the Department. All communication and submissions in response to this RFQ should be

addressed to: Pennsylvania Insurance Department, Attention: Peter J Salvatore, Bureau of

Administration 1326 Strawberry Square, Harrisburg, Pennsylvania 17120. This issuing office is

the sole point of contact in the Commonwealth for receiving and processing all completed

submission packages in response to this RFQ. All questions should be emailed to: RA-IN-

EXAM-RFQ2013-001@pa.gov.

Purpose:

The purpose of this RFQ is to allow the Department to qualify vendors to assist in either full-

scope or limited-scope financial examinations of domestic insurance companies. Examinations

work must be completed in accordance with Pennsylvania laws and regulations, the National

Association of Insurance Commissioners (“NAIC”) Financial Condition Examiners Handbook,

the NAIC Accounting Practices & Procedures Manual, and, where applicable, in compliance

with the NAIC Financial Regulation Standards and Accreditation Program. This qualification

process contains no guarantee of engagement to perform work for the Department.

Minimum Requirements:

Vendors must have prior documented experience in performing the principal services for which

qualification is requested as listed in item 2 of Attachment A – Questionnaire.

Tentative Schedule:

All responses to this RFQ must be received by the Department’s Issuing Office by no later than

3:00 EST on August 2, 2013. The Department reserves the right to reject any submission

received after that time. The Department anticipates qualifying vendors by August 31, 2013 for

services to be provided on an “as needed” basis, based upon Department need for outside

expertise, from September 1, 2013 through August 31, 2016.

Requirements for Qualification:

In order for a vendor to be considered for qualification and in order for the Department to accept

a response to this RFQ as “complete,” prospective vendors must submit each of the following

items with their response labeled as identified below:

TAB A – Completed and signed –Questionnaire (included with this RFQ as Attachment

A)

TAB B – Completed and signed Fee Schedule (included with this RFQ as Attachment B)

TAB C – Signed attestation from a Corporate Officer with authority to bind the

prospective vendor that the vendor and its staff will be able to comply with the terms of

the Vendor Computer Use Agreement (included with this RFQ as Attachment C), which

the Department will require execution of should an engagement be entered into between

the Department and the vendor

TAB D – Completed and signed Department of General Services (“DGS”) Non-

Collusion Affidavit (included with this RFQ as Attachment D)

TAB E – Completed and signed Domestic Workplace Utilization Form (included with

this RFQ as Attachment E)

All responses to this RFQ must be received by the Department’s Issuing Office by no later than

3:00 EST on August 2, 2013. The Department reserves the right to reject any submission

received after that time, as well as any submission that does not contain the information

identified above. Two (2) hard copies and one electronic copy of the entire completed

submission package must be provided to the issuing office. The Department will evaluate each

vendor’s qualifications based solely on the information provided in the completed submission

package. The final evaluation and qualification will be made by the Department. Failure to

respond completely and accurately to each individual item in the questionnaire and all

accompanying attachments may result in disqualification from further consideration. All

materials received will become the sole and exclusive property of the Department.

Selection and Engagement of Vendors:

The Department will review all submissions for qualification and notify all vendors that made a

submission in response to this RFQ of the outcome of the review. All qualified vendors will be

assigned to a list maintained by the Department’s Bureau of Financial Examinations. The order

of vendors on the list will be randomly generated. When a need for financial examination

support services arises, the Department will consider for use and contact the next vendor on the

list that is qualified to provide the needed services and does not present an actual, perceived or

potential conflict of interest. If during this process, the Department determines that:

the vendor cannot complete all or any part of an engagement within the timeframes

required by the Department; and/or

the personnel proposed for the engagement do not have the required expertise;

the Department may, in its discretion, offer the engagement to the next qualified vendor for

consideration. Upon selection by the Department from the qualified vendor list as described

above, the vendor will be required to execute an Engagement Letter with the Department that

will specify the terms of the engagement, the scope of the work to be performed, and other

information relating to the payment for the services performed by the insurance company that is

the subject of the examination.

ATTACHMENT A

QUESTIONNAIRE

Attachment A - Questionnaire

Date Completed:

Instructions: This form must be completed, signed and submitted by all vendors responding to

the Request for Qualifications. Responses must be provided for each individual item in the

questionnaire and all accompanying attachments. The Department’s review of the vendor’s

qualifications will be based entirely and exclusively upon the responses to this questionnaire

and all accompanying attachments.

Information on Proposing Vendor

1. Vendor Name:

Vendor Address:

Contact Person:

Contact E-mail:

Contact Telephone:

Federal ID Number:

2. Principal services offered by vendor. Please indicate by checking the box(es) below for

each of the services you wish to be qualified.

□ Principal Service 1. Risk-Focused Examination (“RFE”) Services:

Obtain and Document an Understanding of the Company and Identify Key

Functional Activities (Phase 1)

Identify and Assess Inherent Risk (Phase 2)

Identify and Assess the Company’s Key Controls (Phase 3)

Determine Residual Risk (Phase 4)

Design and Execute the Substantive Testing Plan (Phase 5)

Provide Examination Reporting Services (Phase 6)

Examination Follow-Up (Phase 7)

□ Principal Service 2. IT Control Assessment Services:

Review the insurer’s completed IT Planning Questionnaire (ITPQ) and assist

the Examiner In Charge (“EIC”) during the planning process

Determine the scope of the IT General Controls to be reviewed

Prepare an IT planning memorandum

Create a mapping of the critical data path for significant financial and

operational systems

Evaluate the controls within the IT work program using the NAIC IT

Questionnaire Part II

Conduct IT examination field work, that shall include interviews with key IT

staff, and testing the IT General Controls

Evaluate and utilize the work papers prepared internally by the insurer and/or

external parties such as CPA audit work papers, ERM, SOX, COSO, MAR,

SSAE16 and all audits related to IT

Document the results of the IT General Controls Review, which shall include

a summary of findings regarding the insurer’s IT environment

Assist on the financial examination during Phases 3 through 5 for Computer

Aided Auditing Techniques using ACL, participate during the process

walkthroughs of application Control Testing, and identify automated and

hybrid controls.

Communicate the IT risks to the Examination Team

Document the impact of IT application control results relating to the financial

examination control testing

Principal Service 3. Actuarial Support Services:

□ Phases 1 through 4 RFE work for Actuarial related key activities

□ Phases 5 through 7 RFE work for Property & Casualty insurance

□ Phases 5 through 7 RFE work for Life and Accident & Health

insurance

□ Principal Service 4. Investment Services:

Specialized Investment Analysis

3. Describe the organizational structure of the vendor (corporation, etc.), its affiliation with

other companies (parent, subsidiary, etc.), and the vendor’s employment model

(employees, independent contractors/subcontractors, etc.) with respect to the services

checked above.

4. Office location and / or personnel residing in Pennsylvania, if applicable.

5. (a) How long has the vendor been in business?

(b) How long has the vendor been providing insurance regulatory support services with

respect to each of the services that the vendor wishes to be qualified as checked in item 2

above.

Principal Service Requirements 6. Vendors should respond directly and in detail as to their capabilities and prior experience to

perform each principal service for which they are requesting qualification in item #2. For

each requested principal service, the vendor must also demonstrate their qualifications and

prior experience to:

Conduct examinations that meet NAIC Accreditation Standards, using the NAIC

Risk-Focused Examination (“RFE”) approach, as prescribed in the NAIC Financial

Condition Examiners Handbook.

Perform work using statutory accounting principles, as prescribed in the NAIC

Accounting Practices & Procedures Manual, Annual Statement Instructions and

Securities Valuation Office procedures.

Obtain and utilize TeamMate electronic software in providing financial examination

support services. (Optional for Principal Service 3. Actuarial Support Services)

Document any findings or deficiencies to the Department on a timely basis.

Provide the Department constant and continuous access to all workpapers regardless

of the quality control aspects set in place by the vendor.

Perform examinations in accordance with Pennsylvania’s laws and regulations.

Maintain security of workpapers in compliance with the Department’s Vendor

Computer Use Agreement.

For Actuarial Support Services (Phases 1 through 4), perform an assessment of an

insurer’s internal processes related to reserving, pricing/underwriting, liquidity and/or

reinsurance.

Provide on-the-job training, as needed, to Department staff assigned to the

examination.

Provide subject matter experts to assist Department staff.

Testify in regulatory or legal proceedings relating to financial examination support

services provided to the Department.

Be available, if and when, an examination is selected for review by an NAIC

Accreditation Review Team.

Provide follow-up services relating to examination recommendations, management

letter comments and supervisory plans.

Ensure examinations completed by vendor staff will meet NAIC Accreditation

Standards.

Vendor Facilities

7. Describe the vendor’s capability to perform work and provide documentation using

software applications compatible with TeamMate, such as, but not limited, to the

following:

Documents and spreadsheets (e.g., MS Word, Adobe, and MS Excel)

Process flow charts and network diagrams (e.g., MS Visio)

Data analysis (e.g., ACL)

Describe the vendor’s standard computer configuration requirements, including type of

hardware, operating system, encryption and anti-malware software used.

Client Information

8. Does the vendor provide services where an actual, perceived or potential conflict of interest

may occur with an insurance company?

Yes _____ No _____

If yes, identify those companies on a separate list (this may affect whether a consultant

would be allowed to work on an individual company where there is a potential conflict, but

would not be disqualified in any general sense).

9. Has the vendor performed Risk-Focused Examinations or provided actuarial support to a

Risk Focused Examination for other state insurance departments since January 1, 2010?

Yes _____ No _____

If yes, provide the state(s) and the name(s) of the insurance department personnel, along

with their contact information, who have knowledge of the vendor’s experience. Then,

beneath each state listed, identify the insurance company (or group) examined, as well as

the examination as of date.

10. Has the vendor ever been dismissed from a Financial Examination assignment?

Yes _____ No _____

If yes, provide the state(s) and the name(s) of the insurance department personnel, along

with their contact information, who have knowledge of your experience.

11. Has the vendor been notified by any insurance department that a Financial Examination

performed by the vendor was selected for NAIC peer review or accreditation review?

Yes ______ No_______

If yes, provide a summary of the issues raised, and the name(s) of the insurance department

personnel, along with their contact information, who have knowledge of the NAIC review.

Training and Quality Assurance

12. Describe the vendor’s process for ensuring that staff participates in ongoing training

relevant to Risk-Focused Examination processes, including, but not limited to NAIC

training and/or other organizations offering CPE training.

13. List the individual names from the vendor’s staff that participated in the NAIC’s recent

training entitled, “Risk-Focused Examinations – The Role of the Examining Actuary”.

14. Describe the vendor’s processes for peer review and quality assurance.

Conflict of Interest

15. Describe what method the vendor utilizes to identify or resolve any conflicts of interest,

actual, perceived or potential, prior to accepting a work assignment/examination

engagement.

Fee Schedule

16. Insurance companies for which the services will be performed will pay the Department’s

engaged vendors based upon an hourly fee schedule and actual expenses. Vendors are

required to assign the work to the lowest billing personnel classification qualified to do that

level of work in order to minimize the cost of the exam. Complete and sign the Fee

Schedule included with this RFQ as Attachment B. Your fee schedule will be reviewed to

ensure that the fees are reasonable and consistent with prevailing market rates.

The Department utilizes a holdback provision for professional fees on every vendor

engagement. In addition, the Department will not permit a vendor to charge and bill for

indirect or other similar expenses on anything other than actual costs incurred.

Miscellaneous overhead or indirect cost add-ons will not be reimbursed. Actual travel and

related expenses will be billed to the company being examined as an additional expense in

accordance with the Commonwealth of Pennsylvania’s travel policy and procedures in

effect at the time of the engagement. The Commonwealth travel policies in effect at the

time of publication of this RFQ may be found at the following link:

http://www.portal.state.pa.us/portal/server.pt?open=514&objID=551881&mode=2

Personnel

17. List the personnel qualified to provide each principal service checked in item 2 above on a

separate page. Attach resumes for these individuals including the number of years of

insurance industry experience, a description of regulatory examination work performed;

identify the maximum hourly billing rate for each, and any other information that supports

the hourly billing rate. Use the following billing classifications for all personnel, including

subject matter experts:

Vendor Supervisory Partner: responsible for overall client relationship, peer review,

quality control and ensuring a coordinated client service delivery process.

Financial Examination Manager: can serve as the Examiner-in-Charge or assist the

Vendor Supervisory Partner with review and client service matters. Must maintain an

active Certified Financial Examiner (“CFE”) designation.

Examiner-in-Charge (“EIC”): responsible for the day-to-day management of the

examination procedures performed by staff examiners. The EIC ensures appropriate

approval and execution of all risk focused examination procedures, and that the

Department’s needs are completely met or exceeded. Must maintain an active CFE

designation.

Senior Financial Examiner: works closely with the EIC in the conduct of the risk focused

examination procedures, administration functions of the examination and in the supervision

of other staff members. Must maintain an active CFE designation.

Staff Financial Examiner: performs specific examination procedures under the direction

of the EIC and/or Senior Financial Examiner.

Lead IT Specialist/Manager: works closely with the EIC in the identification of critical

data and systems, the evaluation of the company’s IT governance structure, and the

identification and assessment general IT controls and application specific IT controls and

their impact on the integrity and availability of company’s critical data. Must maintain an

active Certified Information Systems Auditor (“CISA”) certification. An active Automated

Examination Specialist (“AES”) designation is strongly preferred.

Senior IT Specialist: supports Lead IT Specialist/Manager and may work closely with the

EIC in the conduct of the risk focused IT examination procedures and in the supervision of

Staff IT Examiners. Must maintain an active CISA certification. An active AES

designation is strongly preferred.

Staff IT Examiner: performs specific IT examination procedures under the direction of

the Lead IT Specialist/manager or Senior IT Specialist.

Actuarial Project Manager: responsible for the overall actuarial plan and deliverables,

maintains primary contact with the Department, and ensures quality control over the entire

project. This actuary must maintain membership in the American Academy of Actuaries

(“AAA”) and maintain credentials from a relevant actuarial society (Casualty Actuarial

Society or Society of Actuaries).

Peer Review Actuary: responsible for peer review of all actuarial work products and

deliverables to ensure technical completeness and to fulfill scope requirements. This

actuary must maintain membership in the AAA and maintain credentials from a relevant

actuarial society (Casualty Actuarial Society or Society of Actuaries).

Analysis Actuary: provides assistance to the actuarial scope of work at various levels and

provides specialized skill sets where needed. This actuary must maintain membership in

the AAA and maintain credentials from a relevant actuarial society (Casualty Actuarial

Society or Society of Actuaries).

Actuarial Student / Staff Actuary: provides data entry, data analysis and/or other

technical support to the actuarial scope of work where needed. Actuarial credentials are

not required.

Investment Specialist: provides specialized knowledge and analysis related to investment

portfolio holdings.

Clerical and Administrative support: performs photocopying, faxing, scheduling, billing,

and various other administrative duties in support of the engagement that would not be

performed by any of the professional classifications listed above.

Signature

18. I hereby confirm that this response, including attachments, is accurate, that the fees

identified in the Fee Schedule will be the maximum offered for all work performed from

September 1, 2013 through August 31, 2016, and that I have authority to bind the

submitting vendor to the terms and conditions identified in this RFQ.

Signature Title Date

ATTACHMENT B

FEE SCHEDULE

Attachment B - Fee Schedule

Date Completed:

Instructions: All vendors shall provide the maximum hourly billing rate charged per Personnel

Billing Classification for the personnel identified in Attachment A, Item 17. If the vendor

charges a minimum/maximum hourly billing rate depending on the specific employee within a

classification, identify the minimum/maximum hourly billing rate range and provide a reason or

other justification for the use of the hourly billing rate range, as opposed to a single maximum

hourly billing rate.

Vendor Name:

Vendor Address:

Contact Person:

Contact E-mail:

Contact Telephone:

Federal ID Number:

Personnel Billing Classification Hourly Billing Rate

ATTACHMENT C

VENDOR COMPUTER USE

AGREEMENT

(COMPLETED AND SIGNED AT TIME OF

ENGAGEMENT)

Attachment C – Vendor Use Agreement

Bureau of Financial Examinations

Vendor Computer Use Agreement

Vendor Name (“Vendor”) shall be examining Company Name (“Company”) pursuant to the Initial

Engagement Letter for Financial Examination Support Services #000-00000-13-R. In order to perform

this function, it will be required to access the Pennsylvania Insurance Department’s (“Department”)

System using consultant equipment (i.e., laptops). To protect the integrity and security of the

Department’s servers, networks and data, it is required that any and all equipment interfacing with the

Department’s WAN and LAN be protected from data theft, misuse and electronic attack (this includes,

but is not limited to, viruses, worms, Trojans, BOTs and any kind of spyware/malware/adware).

Therefore the Vendor hereby attests that the computer equipment used by it on this examination has

firewall, anti-virus and spyware detection programs installed and that routine security updates will be

performed as dictated by the programs used to protect the machines. The Vendor further attests that all

laptops will be password protected and that protocols for data protection, access and passwords will meet

the requirements of the following state information security policies and standards (available at http://www.portal.state.pa.us/portal/server.pt?open=512&objID=416&&PageID=210791&mode=2&in_hi_userid=2

&cached=true):

ITB-SEC007 (Minimum Standards for User IDs and Passwords)

ITB-SEC019 (Policy and Procedures for Protecting Commonwealth Electronic Data)

ITB-SEC020 (Encryption Standards for Data at Rest)

ITB-SEC024 (Information Technology Security Incident Reporting Policy)

ITB-SEC031 (Encryption Standards for Data in Transit)

By: _________________________________________________ [Signature of] Authorized Representative Date

title

Each Vendor staff member accessing the Insurance Department’s WAN/LAN (individuals who

will be receiving user IDs), by their signatures below, hereby agree to abide by the terms of the

foregoing Agreement:

Staff member Name (print and signature) Date

Staff member Name (print and signature) Date

Staff member Name (print and signature) Date

Staff member Name (print and signature) Date

This Agreement, when fully executed, is to be forwarded to the Department for User ID assignment.

ATTACHMENT D

NON-COLLUSION

AFFIDAVIT

INSTRUCTIONS FOR NONCOLLUSION AFFIDAVIT

1. This Noncollusion Affidavit is material to any contract/purchase order awarded pursuant to

this bid. According to Section 4507 of Act 57 of May 15, 1998, 62 Pa. C.S. § 4507,

governmental agencies may require Noncollusion Affidavits to be submitted with bids.

2. This Noncollusion Affidavit must be executed by the member, officer, or employee of the

bidder who makes the final decision on prices and the amount quoted in the bid.

3. Bid rigging and other efforts to restrain competition, and the making of false sworn

statements in connection with the submission of bids are unlawful and may be subject to criminal

prosecution. The person who signs the affidavit should examine it carefully before signing and

assure himself or herself that each statement is true and accurate, making diligent inquiry, as

necessary, of all other persons employed by or associated with the bidder with responsibilities

for the preparation, approval or submission of the bid.

4. In the case of a bid submitted by a joint venture, each party to the venture must be identified

in the bid documents, and an affidavit must be submitted separately on behalf of each party.

5. The term “complementary bid” as used in the affidavit has the meaning commonly associated

with that term in the bidding process, and includes the knowing submission of bids higher that

the bid of another firm, any intentionally high or noncompetitive bid, and any other form of bid

submitted for the purpose of giving a false appearance of competition.

6. Failure to submit an affidavit with the bid proposal in compliance with these instructions may

result in disqualification of the bid.

NONCOLLUSION AFFIDAVIT

Contract/Requisition No. ________________

State of _____________________ :

County of _____________________ : s.s.

I state that I am (Title) of (Name of Firm) and that I am

authorized to make this affidavit on behalf of my firm, and its owners, directors, and officers. I am the person

responsible in my firm for the price(s) and the amount of this bid.

I state that:

(1) The price(s) and amount of this bid have been arrived at independently

and without consultation, communication or agreement with any other contractor, bidder or potential bidder.

(2) Neither the price(s) nor the amount of this bid, and neither the approximate price(s)

nor approximate amount of this bid, have been disclosed to any other firm or person who is a bidder or

potential bidder, and they will not be disclosed before bid opening.

(3) No attempt has been made or will be made to induce any firm or person to refrain

from bidding on this contract, or to submit a bid higher than this bid, or to submit any intentionally high or

noncompetitive bid or other form of complementary bid.

(4) The bid of my firm is made in good faith and not pursuant to any agreement or

discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive

bid.

(5) (Name of Firm) its affiliates, subsidiaries, officers, directors, and

employees are not currently under investigation by an governmental agency and have not in the last four years

been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving

conspiracy or collusion with respect to bidding on any public contract, except as follows:

I stated that (Name of Firm) understands and acknowledges that the above

representations are material and important, and will be relied on by (Name of Purchasing Agency)

in awarding the contract(s)/purchase order (s) for which this bid is submitted. I understand and my firm

understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from the

Purchasing Agency of the true facts relating to the submission of this bid.

_______________________________ _______________________________

(Signature) (Signatory’s Name)

_______________________________

(Signatory’s Title)

SWORN TO AND SUBSCRIBED

BEFORE ME THIS _________DAY

OF ___________________ 20 _____

______________________________

My Commission Expires ___________________

Notary Public

ATTACHMENT E

DOMESTIC WORKFORM

UTILIZATION FORM

DOMESTIC WORKFORCE UTILIZATION CERTIFICATION FOR MULTIPLE

AWARD CONTRACTS (07/24/09)

To the extent permitted by the laws and treaties of the United States, this certification will be used by the Agency in

making a best value selection for each particular assignment. Each quote will be evaluated for its commitment to use

the domestic workforce in the fulfillment of the contract. Maximum consideration will be given to those suppliers

who will perform the contracted direct labor exclusively within the geographical boundaries of the United States or

within the geographical boundaries of a country that is a party to the World Trade Organization Government

Procurement Agreement. Those who propose to perform a portion of the direct labor outside of the United States

and not within the geographical boundaries of a party to the World Trade Organization Government Procurement

Agreement will receive a correspondingly smaller score for this criterion. In order to be eligible for any

consideration for this criterion, suppliers must complete and sign the following certification. This certification will

be included as a contractual obligation when the contract is executed. Failure to complete and sign this certification

will result in no consideration being given to the supplier for this criterion.

I, ______________________[title] of ____________________________________[name of Contractor] a

_______________ [place of incorporation] corporation or other legal entity, (“Contractor”) located at

________________________________________________________________ [address], having a Social Security

or Federal Identification Number of ________________________, do hereby certify and represent to the

Commonwealth of Pennsylvania ("Commonwealth") (Check one of the boxes below):

All of the direct labor performed within the scope of services under the contract will be performed

exclusively within the geographical boundaries of the United States or one of the following countries that is

a party to the World Trade Organization Government Procurement Agreement: Aruba, Austria, Belgium,

Bulgaria, Canada, Chinese Taipei, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany,

Greece, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Liechtenstein, Lithuania,

Luxemburg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Singapore, Slovak Republic,

Slovenia, Spain, Sweden, Switzerland, and the United Kingdom

OR

________________ percent (_____%) [Contractor must specify the percentage] of the direct labor

performed within the scope of services under the contract will be performed within the geographical

boundaries of the United States or within the geographical boundaries of one of the countries listed above

that is a party to the World Trade Organization Government Procurement Agreement. Please identify the

direct labor performed under the contract that will be performed outside the United States and not within

the geographical boundaries of a party to the World Trade Organization Government Procurement

Agreement and identify the country where the direct labor will be performed:

______________________________________________________________________________________

____________________________________________________

[Use additional sheets if necessary]

The Department of General Services [or other purchasing agency] shall treat any misstatement as fraudulent

concealment of the true facts punishable under Section 4904 of the Pennsylvania Crimes Code, Title 18, of Pa.

Consolidated Statutes.

Attest or Witness: ______________________________

Corporate or Legal Entity's Name

____________________________ ______________________________

Signature/Date Signature/Date

_____________________________ ______________________________

Printed Name/Title Printed Name/Title