ࡱ                >  	               Q         S         N  O  P   %`	               d   bjbj                  	 \R ̟  ̟  &      %               (                                                                   F      F      F  $           j      E      E      E  P   F  t  G    j           "J  N  pZ  "   Z      Z      Z      <\    6^  ,  b_     s     u      u      u      u      u      u  $     h                            F      <a                      \  "   8\     <a      <a                                Z              Z    z     n      n      n      <a  ^     8   Z      F      Z      s              n                                                      <a      s              n      n     ߂     .     F                                                              τ      Z      J     0B        E      a                    t    0           6        Xb  4    ,   τ                                                                                            F      τ  0  _  0   *`  "   n      L`     h`                                     _      _      _                                                  n  ^                                   _      _      _            <a      <a      <a      <a              j      j      j  d@  E      j      j      j      E      j      j      j                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 C A R E G I V E R   C O U R T   I N F O R M A T I O N   F O R M    C h i l d :        F O R M T E X T            L e g a l   C a s e   N u m b e r   ( i f   k n o w n ) :     F O R M T E X T             D . O . B :        F O R M T E X T            H e a r i n g   D a t e :        F O R M T E X T               T o   t h e   F o s t e r   P a r e n t   o r   R e l a t i v e / K i n s h i p   C a r e g i v e r   o f   t h e   c h i l d :     Y o u   h a v e   t he right to be present at hearings and you are encouraged to attend.  You also have a right to be heard at review and permanency hearings.  You may appear and provide information verbally.  You may also submit written information to the court.  Any information you provide may or may not be admitted into evidence.  If the information is not admitted, the Judge will not see it.  All parties to the case will have access to the information you provide.  You may be called to testify.  Provide only factual information of which you have first-hand knowledge.  You do not have to complete every item on the form.  You are not required to provide written information to the court.  If you decide to complete the form, please type or print clearly in ink and submit the form two weeks in advance of the hearing to the Juvenile Office where the hearing will take place.  Social Security Act section 438(b)(1), 475(5)(G), 42 U.S.C. 629g(b)(1), 675(5)(G), 211.171 RSMo, 211.464 RSMo, 210.566 RSMo1.  Childs Name:      FORMTEXT           	 	 	 	 	 	                                        A g e :              F O R M T E X T               2 .     N a m e   o f   C a r e g i v e r :        F O R M T E X T                         T y p e   o f   C a r e g i v e r :   F o s t e r   P a r e n t                 	    F O R M C H E C K B O X                               	 	 R e l a t i v e / K i n s h i p 	    F O R M C H E C K B O X                 	 	 	 O t h e r   ( s p e c i f y ) :              F O R M T E X T               3 .     T h e   c h i l d   h a s   b e e n   l i v i n g   i n   m y   h o m e   f o r      F O R M T E X T             y e a r s   a n d      F O R M T E X T             m o n t h s .          N a m e   o f   C a r e g i v e r :        F O R M T E X T                                                               L e g a l   C a s e   N u m b e r :        F O R M T E X T             N a m e   o f   C h i l d :        F O R M T E X T              4 .     L i s t   C h i l d  s   M e d i c a l   o r   D e n t a l   A p p o i n t m e n t s   w h i c h   w e r e   s i g n i f i c a n t :   D a t e  T y p e   o f   A p p t  M e d i c a l   P r o v i d e r  D i a g n o s i s  M e d i c a t i o n s  R e q u i r e d   F o l l o w - u p   ( y e s   o r   n o )   E x a m p l e :  1 2 / 5 / 0 7  E x a m p l e :  M e d i c a l - E a r    E x a m p l e :  D r .   J o n e s  E x a m p l e :  E a r   i n f e c t i o n  E x a m p l e :  A m o x i c i l l i n  E x a m p l e :  Y e s - m a y   n e e d   t u b e s      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T              5 .     L i s t   C h i l d  s   M e n t a l   H e a l t h   A p p o i n t m e n t s   w h i c h   w e r e   s i g n i f i c a n t :   D a t e  T y p e   o f   A p p t  M e d i c a l   P r o v i d e r  D i a g n o s i s  M e d i c a t i o n s  R e q u i r e d   F o l l o w - u p   ( y e s   o r   n o )      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T              6 .     C h i l d  s   S i g n i f i c a n t   B e h a v i o r   D a t e / T i m e  D e s c r i p t i o n   o f   B e h a v i o r   E x a m p l e :     1 1 / 2 8 / 0 7 -   5 : 3 0   p . m .  E x a m p l e :     D a v i d   t h r e w   a   c h a i r ,   w e n t   t o   h i s   r o o m ,   l o c k e d   t h e   d o o r   a n d   w o u l d   n o t   s p e a k   t o   a n y o n e   f o r   t h e   r e s t   o f   t h e   e v e n i n g .      F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               N a m e   o f   C a r e g i v e r :              F O R M T E X T                                                                 L e g a l   C a s e   N u m b e r :      F O R M T E X T             N a m e   o f   C h i l d :        F O R M T E X T             7 .     C u r r e n t   s t a t u s   o f   t h e   C h i l d  s   E d u c a t i o n   G r a d e   i n   S c h o o l          F O R M T E X T            N a m e   o f   S c h o o l          F O R M T E X T             T h e   c h i l d :           	    F O R M C H E C K B O X       h a s   c h a n g e d   s c h o o l s   s i n c e   t h e   l a s t   h e a r i n g                                              	    F O R M C H E C K B O X       h a s   c h a n g e d   s c h o o l s      F O R M T E X T             t i m e s     F O R M C H E C K B O X       h a s   n o t   c h a n g e d   s c h o o l s   s i n c e   t h e   l a s t   h e a r i n g   T h e   c h i l d :     	    F O R M C H E C K B O X       h a s   r e c e i v e d   a   r e p o r t   c a r d   s i n c e   t h e   l a s t   h e a r i n g  	         	    F O R M C H E C K B O X       h a s   n o t   r e c e i v e d   a   r e p o r t   c a r d   s i n c e   t h e   l ast hearing(NOTE: Please attach a copy of the report card if available.)The child:	 FORMCHECKBOX  is a special education student	    	 FORMCHECKBOX  is not a special education student Date of the last Individual Education Plan (IEP) if applicable:   FORMTEXT                                                                                                                                                                                                                                                       D i d   y o u   a t t e n d ? 	    F O R M C H E C K B O X     Y e s                                                                  	    F O R M C H E C K B O X     N o   7 . a .     T u t o r i n g / S p e c i a l   s e r v i c e s   n o t   c o v e r e d   b y   a n   I E P   a n d / o r   E d u c a t i o n a l     A c h i e v e m e n t s :   D a t e  T u t o r i n g / S p e c i a l   S e r v i c e  S p e c i a l   R e c o g n i t i o n   E x a m p l e :     1 0 / 1 3 / 0 7   E x a m p l e :     D a v i d   w a s   s e l e c t e d   f o r   S p e l l i n g   B e e      F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T              8 .     O l d e r   Y o u t h   I s s u e s   ( F o r   c h i l d r e n   1 4   a n d   o l d e r )   T h e   A n s e l l - C a s e y   L i f e   S k i l l s   A s s e s s m e n t : 	    F O R M C H E C K B O X       h a s   b e e n   c o m p l e t e d   i n   p a s t   y e a r                	    F O R M C H E C K B O X       h a s   n o t   b e e n   c o m p l e t e d     T h e   c h i l d   i s   i n   n e e d   o f   t h e   f o l l o w i n g   l i f e   s k i l l s :      F O R M T E X T                  N a m e   o f   C a r e g i v e r :        F O R M T E X T                                                                               L e g a l   C a s e   N u m b e r :        F O R M T E X T             N a m e   o f   C h i l d :        F O R M T E X T              8 a .     E d u c a t i o n a l / V o c a t i o n a l / P o s t - S e c o n d a r y   I n t e r e s t :      F O R M T E X T                     9 .     C h i l d  s   E x t r a   C u r r i c u l a r   A c t i v i t i e s / S p e c i a l   I n t e r e s t s   ( i . e .   A t h l e t i c ,   F i n e   A r t s ,           O t             B  F  R  V  X  l  n  p  z  |                              
	  	  	  	  	  6	  :	  <	  P	  R	  T	  ^	  `	  d	  	  	  	  	  	  F
  ͺŬѨ͝ŬѨ͒ŬŨ͇ŬŨу{  hF*  h`:  hI{  j  hN UjC  hEU Ujt   hN Uhq  j    h't UmH nH u j    hEU Uj    hN UhN  hLIC  hLIC 5>* h-9 5>*CJ aJ  hI{ 5>*CJ aJ  h~ hLIC 5>*CJ aJ 0   B  D  F  ~        	  b	                                                                          n                                                                                                   {  kd   $$If   s              0 %" L                 L                
t  0                                                            4   4 
s a  	  $If   gdS    gdLIC    $a$gd=jY  	       b                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           b	  d	  f	  h	  c                                        v            v                                                                                                                                                               	  $If   gdS    gdLIC {  kd!  $$If   s             0 %" L                 L                
t  0                                                            4   4 
s a   F
  J
  O
  [
  _
  
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         +  <  |              	      "  .  /  B  J  a  b  c  e          *  _  `  a  b  c                                hA2 hA2 CJ aJ  h? hA2  h<I] CJ aJ  h<I] h<I] 5CJ aJ h<=  h5  h?O  hq  h7 hI{ 5h7 hy' 5	hy' 6hy'  h@9#  h1  h~O  hlL  h3l  hF*  hLIC 8      "                                            |            >            5            	  $If   gdl >  kd  $$If   l  ," "                
t    6              4   4 
l a   $If   ^ gdA2 	  $If   gd<I]    gdLIC  g  kd|  $$If   l              ," "                
t  0                                6                4   4 
l a                        H  N  T  Z  \  p  r  t  ~                                @  B  D  趮趃{kgg\j    hA2 hA2 UhA2  j  hA2 hA2 >*U h<I] CJ aJ  h<I] h<I] 5CJ aJ j9  hA2 hA2 >*U h? CJ aJ  h? hA2  hA2 CJ aJ  hA2 hA2 CJ aJ  j    h't >*UmH nH uj  hA2 hA2 >*U hA2 hA2 >*j    hA2 hA2 >*U h<I]  hA2 hA2 $                                    z            q            3                         >  kd  $$If   l  ," "                
t    6              4   4 
l a	  $If   gdl >  kd  $$If   l  ," "                
t    6              4   4 
l a	  $If   gd<I] >  kd)  $$If   l  ," "                
t    6              4   4 
l a D  `  b  d  p                               *  ,  4  8  <                                  
  ǿǠǿǠǿtǠfj    h91 UmH nH u j	  hA2 hA2 >*U j]	  hA2 hA2 >*U h<I]  h<I] h<I] 5j    h't >*UmH nH uj  hA2 hA2 >*U hA2 hA2 >*j    hA2 hA2 >*U j  h?Q UhA2  j    hA2 hA2 Uj  h?Q UhA2 hA2 (  f  h      .  0                                      z                        <                          >  kde  $$If   l  ," "                
t    6              4   4 
l a>  kdu  $$If   l  ," "                
t    6              4   4 
l a>  kd  $$If   l  ," "                
t    6              4   4 
l a	  $If   gdl  0  2  4                                            q                                                                                                                                                                 >  kdE
  $$If   l  ," "                
t    6              4   4 
l a	  $If   gd<I] >  kd  $$If   l  ," "                
t    6              4   4 
l a	  $If   gdl    
          .  0                                                                          K                                        g  kd  $$If   l              ," "                
t  0                                6                4   4 
l a  	  $If   gdS    gdLIC >  kd
  $$If   l  ," "                
t    6              4   4 
l a 
        :  <  P  R  T  ^  `                                     *  ,  0  2  :  j  l        Z  r  v    ߼귲؟߼ؑ߼ꉄwsosj   	hb 6hf,  h\  h5 h`: 5	h`: 5	h<I] 5h5 hLIC 5j%  hN hN Uj  hN hN U	hN 5	h? 5	hD~ 5j    h't UmH nH u j=  hN hN UhN hN  j    hN hN U	hLIC 5hLIC  h*  h hLIC 5 )0  2          
    6  t                                                                                                                                                                                                                                                                                                                                                                                                       	  $If   gd`:     ^ gd`:    ^gd@9#    h^hgdLIC  	t  v          :            1            1            1            1                     	  $If   gd`:   kd  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a                           *  @  B  T  Z  x  z  |  ~                                            
              2  ͿԱͣԱ͕Ա͇Ա                     j  hN hN Uj2  hN hN Uj  hN hN Uj    h't UmH nH u jJ  hN hN UhN hN  j    hN hN Uh\  	h-xn 6	h^ 6	hb 6hq h\ 6	hq 6 1          *  B  T  z                                                                                                                                                                                                                                                                                                                                                                                                                                                                  	  $If   gd`:  z  |          :            1            1            1            1                     	  $If   gd`:   kd  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a   2  4  6  @  B  D  F  Z  \  ^  h  j  n  p                                                   
        $  &  (  2  4  Ϳͱ͑̓͟uj  hN hN Uj  hN hN Uj  hN hN Uj*  hN hN UhN  j  hN hN Uj  hN hN UhN hN  h\  j    h't UmH nH u j    hN hN Uj  hN hN U .  D  l  n                            1            (                    	  $If   gdEU   kd  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a  	  $If   gd`:          6  ^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 	  $If   gdEU  4  6  8  L  N  P  Z  \  `  b  v  x  z                                                           $  &  (  *  >  @  B  L  zjf  hN hN Uj  hN hN Uj~  hN hN Uj
  hN hN Uj  hN hN Uj"  hN hN Uj    h't UmH nH u j  hN hN UhN hN  j    hN hN UhN 0^  `           :            1            1            1            1                     	  $If   gdEU   kdn  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a      (  P  R  z                            1                                               kd  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a  	  $If   gdEU  L  N  R  T  h  j  l  v  x  z  |                                              
            0  2  4  >  @  D  F  N  {            	h<I] 5hVH hLIC  j  hN hN Uj^  hN hN Uj  hN hN Ujv  hN hN Uj  hN hN Uj    h't UmH nH u j  hN hN UhN hN  hN  j    hN hN U .        B  D                                                  1                       kdF  $$If   l             ֈ G
,"                                                                     T                 X                
t  0                                                                                                            4   4 
l a  	  $If   gdEU  D  F            *  B                                                                                                                                                                                                                                                                                                                                                                                                         	  $If   gdO0    ^gdLIC    ^gd@9#    ^gd`:  	N        f  ~                                                           "  $  8  :  <  F  H  J  L  `  ״װТ״װД״װІ״װx״װ                     jA  hN hN Uj  hN hN UjY  hN hN Uj  hN hN UhN  j    h't UmH nH u jq  hN hN UhN hN  j    hN hN Uhf,  h\  hVH hLIC 6h5 hLIC 5	h\ 5 +          "  :            1            1            1            1                     	  $If   gdEU   kd  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a   "  J  r  t                              1                                               kd)  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a  	  $If   gdEU  `  b  d  n  p  t  v                                                          *  ,  .  8  :  <  >  R  T  V  `  b  f  Ϳͱ͕͇ͣy   j!  hN hN Ujp!  hN hN Uj   hN hN Uj   hN hN Uj   hN hN Uj  hN hN UhN hN  hN  j    h't UmH nH u j    hN hN Uj  hN hN U /      <  d  f                                                  1                       kdX"  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a  	  $If   gdEU  f  h  |  ~                                                             *  ,  .  0  D  F  H  R  T  X  Z  n  p  r  |  y   j%  hN hN Uj%  hN hN Uj$  hN hN Uj+$  hN hN Uj#  hN hN UjC#  hN hN UhN  j    h't UmH nH u j"  hN hN UhN hN  j    hN hN U /f          .  V                                                                                                                                                                                                                                                                                                                                                                                                                                                                            	  $If   gdEU  V  X          :            1            1            1            1                     	  $If   gdEU   kd%  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a   |  ~                                                             "  6  8  :  D  F  J  L  `  b  d  n  p  r  t      y   j)  hN hN Uj-)  hN hN UjB(  hN hN Uj'  hN hN UjZ'  hN hN Uj&  hN hN Uj    h't UmH nH u jr&  hN hN UhN hN  hN  j    hN hN U /     H  J  r                            1                                               kd(  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a  	  $If   gdEU                                                         (  *  ,  6  8  <  >  F  V  n                   ۿ۱ۣ⟚~v            hf, hf, 6	hb 6h\  hP(Y  	heA 6	h? 5	heA 5	h<I] 5hLIC  jq+  hN hN Uj*  hN hN Uj*  hN hN Uj*  hN hN UhN hN  hN  j    h't UmH nH u j    hN hN U ,        :  <                                                  1                       kd+  $$If   s             ֈ Qa%"                                                                                                      
t  0                                                                                                            4   4 
s a  	  $If   gdEU  <  >                                                                            b                                                                                            y  kd\,  $$If   s             0 %" L                 L                
t  0                                                            4   4 
s a  	  $If   gdeA    ^gdeA    ^gd@9#    ^gdLIC                            "   $   &   (   <   >   @   J   L   P   R   f   h   j   t   v   x   z                                                ߼ؗ߼ߓ؅߼ߓw߼ߓ                        j/  hN hN Uj.  hN hN Uh\  j.  hN hN Uj-  hEU UhN  j    hN Uj    h't UmH nH u j%-  hN hN UhN hN  j    hN hN Uhf, hf, 6	hf, 6	hb 6hf, *    &   N   x            o            o                                                                                                                                                                                   	  $If   gdeA    kd,  $$If   s             0 %" L                 L                
t  0                                                            4   4 
s a  p         N   P   x      x            o            o                                                                                                                                                                                   	  $If   gdeA    kd.  $$If   s             0 %" L                 L                
t  0                                                            4   4 
s a  p                                 {            {                                                                                                                                                                                                           	  $If   gdeA {  kdg/  $$If   s             z0 %" L                 L                
t  0                                                            4   4 
s a                           &!  (!  <!  >!  @!  J!  L!  `!  !  !  !  !  !  !  !  !  !  !  !  !  !  "  
"  "  "  "  "  "  $"  r"  t"  漮éü漖Ñ漃zumh              	hLIC 5h5 hLIC 5	h<I] 5	h4 6h4  j1  hN hN U	hN 5jy1  hN hN U	h? 5	hvqK 5j1  hN hN UhN hN  	h4 5	h2  6h\ heA  h\  j    h't UmH nH u j    hN hN Uj60  hN hN U &            !  !  "  "  t"              {            {            T            T            T            {            K                         ^gd@9#  &  $d %d &d 'd N    O    P    Q    gd4    ^gdeA {  kd0  $$If   s             z0 %" L                 L                
t  0                                                            4   4 
s a   t"  v"  "  #  #  #  V$  $  $  |%  &  J&  K&  &  &  (  ^(  (  (  t)  v)                                                                                                                                                                                                                                                           gd4    ^gd@9#    h^hgdLIC    hh^h`hgdEU    hh^h`hgd4    ^`gdN    ^gd4     ^ gd]U  t"  v"  "  "  "  "  "  "  "  "  "  "  "  "  "  "  #  
#  #  #   #  .#  0#  L#  N#  P#  Z#  z#  #  #  #  #  #  #  #  #  #  "$  $$  8$  :$  ޫ榢xh    j14  hN hN >*U j3  h?Q Uh]U  h4  jI3  h?Q Uj    hN UhZ  hN  	h4 >*j2  hN hN >*U hf,  j    h't >*UmH nH uja2  hN hN >*U hN hN >*j    hN hN >*U heA  h5 h]U 5 (:$  <$  F$  H$  V$  X$  t$  v$  x$  z$  $  $  $  $  %  %  %   %  |%  %  %  %  %  %  %  &  I&  J&  K&  T&  V&  W&  e&  f&  g&  k&  }&  &  &  &  &  &  &  &  &  &  &  &  '  '  '  ԺԯઢԏԄ  heA  ju6  h?Q Uj6  h?Q UhLIC  h4  h]U h]U 6	h]U 6j5  h?Q Uj5  h?Q Uh]U  j4  h?Q UhN  j    hN UhZ  j    h't >*UmH nH uj    hN hN >*U2'  '  '  '   (  
(  (  (  ,(  .(  0(  L(  N(  P(  \(  ^(  (  (  (  (  (  (  (  (  (  (  (  Z)  p)  r)  )  )  )  )   *  *  *  *  ^*  `*  b*  d*  ȼȱĭȩȼȞĖ~vqi h h4 6	h 6hZ h4 6	hZ 6	hb 6h4  	hZ 5	h} 5h4 h4 5j7  h?Q UhoN  hZ  j]7  h?Q Uj    hEU UheA  hEU  j    h't >*UmH nH uj6  hEU hEU >*U hEU hEU >*j    hEU hEU >*U)v)  )  )  )  )  *  *  `*                                      l                                                                                                                                                kdE8  $$If   s             F %"                                                   
t  0                                                                      4   4 
s a  	  $If   gd4  `*  b*  *  *  *  s            j            j            j                                                                                                                                                        	  $If   gd4    kd8  $$If   s             lF %"                                                   
t  0                                                                      4   4 
s a   d*  x*  z*  |*  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *   +  +  +  +  +  +  +  (+  *+  ,+  .+  B+  D+  F+  P+  R+  X+  `+  +  +  +  +  +  +  +  כ~   h  h`  h]U  hr heA  	hr 5	h]U 5	h<I] 5j;  hEU Uj+;  hEU Uj:  hEU Uj9  hEU Ujq9  hEU Uh4  j    h't UmH nH u j    hEU Uj8  hEU UhEU 1*  *  +  ,+  T+  s            j            j            j                                                                                                                                                        	  $If   gd4    kdY:  $$If   s             F %"                                                   
t  0                                                                      4   4 
s a   T+  V+  X+  +  +  v,  ,  ,  j-  s            n            e            \            \            S            \            J                       `gd2     ^gdEU    ^gd]U    ^gd@9#    gd4    kd<  $$If   s             F %"                                                   
t  0                                                                      4   4 
s a   +  ,  ,  ,  0,  2,  4,  b,  v,  ,  ,  ,  ,  ,  ,  ,  B-  D-  X-  Z-  \-  f-  h-  j-  r-  t-  v-  -  -  -  -  -  -  -  -  ŽŞř|l]            j    h't 5UmH nH uj=  hEU hEU 5U 	hEU 5j    hEU 5U 	h{7 5h91  	hEU >*	h` >*j    h't >*UmH nH ujY=  hEU hEU >*U hEU hEU >*j    hEU hEU >*U h]U  j<  h?Q Uh`  jq<  h?Q Uj    hEU UhEU  h "j-  l-  n-  p-  r-  v-  X.  Z.  .  .  .  8/  :/  </  >/  @/  B/  D/  F/  H/  J/  4                                                                                                                                                                                                                                                                         L^ `Lgd<=    gd    ^gd@9#  &  $d %d &d 'd N    O    P    Q    gd{7    gd|p'  -  .  .  ,.  0.  2.  F.  H.  J.  T.  V.  v.  z.  |.  .  .  .  .  .  .  /  /  /  &/  (/  */  4/  6/  :/  </  H/  J/  R/  /  /  /   0         "  ᮩzuus                          U	hYd 5h hxc  h<=  j1?  h2  h<I] 5U 	h<I] 5j    h<I] 5U 	h 5	h|p' 5h{7  j>  hEU hEU 5U j    h't 5UmH nH ujE>  hEU hEU 5U j    hEU 5U 	hEU 5	h{7 5	h? 5	h 5 (h e r ) :      F O R M T E X T                     1 0 .     L i s t   C h i l d  s   S t r e n g t h s / T a l e n t s   ( n o t   p r e v i o u s l y   i d e n t i f i e d ) :        F O R M T E X T                       1 1 .     L i s t   a n y   s e r v i c e s   t h e   c h i l d   n e e d s   w h i c h   t h e y   a r e   n o t   r e c e i v i n g :      F O R M T E X T                    N a m e   o f   C a r e g i v e r :          F O R M T E X T                                                                               L e g a l   C a s e   N u m b e r :      F O R M T E X T             N a m e   o f   C h i l d :      F O R M T E X T             N O T E :   L i s t   t h o s e   v i s i t s   f o r   w h i c h   y o u   h a v e   p e r s o n a l   k n o w l e d g e :   1 2 .     T h e   C a s e w o r k e r   h a s   v i s i t e d   t h e   c h i l d :  M o n t h  D a t e s  P l a c e   ( f a c e   t o   f a c e )  P h o n e   C o n t a c t   E x a m p l e :  N o v e m b e r ,   2 0 0 7  E x a m p l e :  1 1 / 3 ; 1 1 / 1 7 ; 1 1 / 2 2  E x a m p l e :   F o s t e r   H o m e   & M c D o n a l d s  E x a m p l e :     1 1 / 1 6      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T              1 3 .     T h e   C a s e w o r k e r   h a s   v i s i t e d   w i t h   F o s t e r   P a r e n t :  M o n t h  D a t e s  P l a c e   ( f a c e   t o   f a c e )  P h o n e   C o n t a c t   E x a m p l e :  N o v e m b e r ,   2 0 0 7  E x a m p l e :  1 1 / 3 ;   1 1 / 2 2  E x a m p l e :  F o s t e r   H o m e  E x a m p l e :  1 1 / 2 8 - C a l l e d   t o   d i s c u s s   i n c i d e n t   d e s c r i b e d   o n   P g . 2      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T              1 4 .     G A L   h a s   v i s i t e d   t h e   c h i l d :  M o n t h  D a t e s  P l a c e   ( f a c e   t o   f a c e )  P h o n e   C o n t a c t      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T              1 5 .     C A S A   v o l u n t e e r   h a s   v i s i t e d   t h e   c h i l d :              C h e c k   h e r e   i f   t h e r e   i s   n o   C A S A   v o l u n t e e r   a s s i g n e d   t o   t h i s   c a s e :   _ _ _ _ _ _  M o n t h  D a t e s  P l a c e   ( f a c e   t o   f a c e )  P h o n e   C o n t a c t      F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                N a m e   o f   C a r e g i v e r :          F O R M T E X T                                                                         L e g a l   C a s e   N u m b e r :      F O R M T E X T             N a m e   o f   C h i l d :      F O R M T E X T                V i s i t a t i o n   w h i c h   t h e   c a r e g i v e r   i s   s u p e r v i s i n g :   M o n t h  D a t e s  I n d i v i d u a l ( s )   t h e   c h i l d   i s   v i s i t i n g   E x a m p l e :  D e c e m b e r ,   2 0 0 7  E x a m p l e :     1 2 / 1  E x a m p l e :     S h i r l e y   D a v i s ,   M o t h e r      F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T                 F a m i l y   S u p p o r t   T e a m   M e e t i n g s :   D a t e  I n d i c a t e   y e s   o r   n o   i f   y o u   a t t e n d e d  D a t e  I n d i c a t e   y e s   o r   n o   i f   y o u   a t t e n d e d   E x a m p l e : 1 1 / 7 / 0 7  E x a m p l e :  N o -   h a d   t o   w o r k        F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                F O R M T E X T               F O R M T E X T               F O R M T E X T               F O R M T E X T                D a t e :      F O R M T E X T                F O R M T E X T           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _             _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  ( T y p e   o r   p r i n t   n a m e )                                                                         ( S i g n a t u r e   o f   C a r e g i v e r   C o m p l e t i n g   F o r m )    P l e a s e   f e e l   f r e e   t o   u s e   t h e   b a c k   i f   e n o u g h   s p a c e   w a s   n o t   p r o v i d e d .               P A G E          P A G E      1      C u r r e n t   p i c t u r e   o f   c h i l d   i f   a v a i l a b l e                                                                                                                                                                                                                                                                                                                                                                                                                                 "  $  &  0  2  6  8  B  F  P  ʤ  ̤                                              ĥ  ƥ  ȥ  Ⱦ״țȎtׄohoco              	h91 5huJ h<I]  	hB 5j@  h2  h<I] 5U j    h<I] 5U 	huJ 5hYd  huJ  hr  j@  h2  hl 5U 	h2  5j    h2  5U 	h|p' 5	hYd 5	h<I] 5	hxc 5	h<= 5j    h't 5UmH nH uj    hEU 5U j?  hEU hEU 5U$4  6  8  :  <  >  @  B  D  F                                                                                                                                                                                                                                                                                                                                ^ gd3     L^ `LgduJ    h^hgd@9#    0^`0gd`     ^ gd      ¥  ĥ  ȥ          r  t  ʧ                                                                                      w            r            r            i                                  h^hgd@9#    gdLIC o  kdkB  $$If   l              ," "                
t  6@M 0                                6                 4   4 
l a    $M&@#$/ If   gd91     ^ gd3  ȥ        
        8  \  h                  Ȧ  ʦ  ̦                $  ,  4  n  p  r  t  x  |  ~  ʧ  ԧ  𚖑zumh    	h8 5h5 hLIC 5	h7P 5	h3 5	h~ 5h hLIC 6	h? 6	h 6hLIC  hF"G hLIC 5jA  hEU hEU 5U jA  hEU hEU 5U 	h? 5	hYd 5j    h't 5UmH nH uj	A  hEU hEU 5U 	hEU 5j    hEU 5U 	hLIC 5 (ʧ  ֧      (  *  <  Z  l    Ψ                                                  W                                                                          kdB  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a  	  $If   gdLIC  
ԧ  ֧      
    &  (  *  <  X  Z  l        ̨  Ψ                
          .  0  2  <  >  @  B  V  X  Z  d  f  h  j  ~                  ϲ˧ϲ˜ϲˑϲˆ    jE  hEU UjD  hEU Uj}D  hEU UjD  hEU Uj    h't UmH nH u jC  hEU UhEU  j    hEU U	hoN 6h h8 6	h 6	hb 6h8  	h8 5h8 h8 5 4Ψ        @  h                W                                                                                                                                  kd*C  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a  	  $If   gdLIC          
  2  `            W            W            W            W                                                                                                 	  $If   gdEU   kdiE  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a               Щ  ҩ  ԩ  ީ                  
       "  $  .  0  4  6  J  L  N  X  Z  \  ^  r  t  v                        ª  Ī  ƪ  Ъ  Ҫ  ֪  ت                             jqI  hEU UjH  hEU UjH  hEU UjH  hEU Uj2G  hEU UjF  hEU UjFF  hEU UhEU  j    h't UmH nH u j    hEU U 72  4  \      Ԫ  `            W            W            W            W                                                                                                 	  $If   gdEU   kdG  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   Ԫ  ֪    &  N  v  `            W            W            W            W                                                                                                 	  $If   gdEU   kdI  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a                        "  $  &  (  <  >  @  J  L  N  P  d  f  h  r  t  x  z                      ī  ƫ  ȫ  ʫ  ޫ                  ڹڮڣژڐ    jM  h91 Uh91  j    h91 UjyM  hEU UjM  hEU UjL  hEU UjK  hEU Uj:K  hEU UjJ  hEU UhEU  j    h't UmH nH u j    hEU UjNJ  hEU U 2v  x    ȫ      `            W            W            W            W                                                                                                 	  $If   gdEU   kd&L  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a     
                       &  <  >  P  f  h  z  ޭ                  
       "  $  .  0  2  4  H  J  L  V  X  Z  \  p  r  t  ~            Ҹ學墸嗸匸凸      	hEU 5jP  hEU UjP  hEU UjP  hEU UjO  hEU Uj    hEU Uh h8 6	h 6	hb 6	h8 5	h 5	h~ 5hLIC  hEU  j    h't UmH nH u j    h91 U 4            Ƭ    `            W            W            N            N            N            N                                             	  $If   gd    h^hgdLIC   kdeN  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a           &  >  P  h  z    `            W            W            W            W            W            W            W            W                             	  $If   gd   kdN  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   	    
  2  Z    `            W            W            W            W                                                                                                 	  $If   gdEU   kd3O  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a         Ԯ    $  `            W            W            W            W                                                                                                 	  $If   gdEU   kdrQ  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a                 ®  Į  Ʈ  Ю  Ү  Ԯ  ֮                         "  $  &  (  <  >  @  J  L  N  P  d  f  h  r  t  v  x                      ¯  ڹڴکڞړڈ   jzU  hEU UjU  hEU UjT  hEU UjT  hEU U	hEU 5j;S  hEU UjR  hEU UjOR  hEU UhEU  j    h't UmH nH u j    hEU UjQ  hEU U 5$  &  N  v    Ư  `            W            W            W            W                                                                                                 	  $If   gdEU   kdS  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   ¯  į  Ư  ȯ  ʯ  ޯ                  
          .  0  2  <  >  @  B  V  X  Z  d  f  h  j  l                              а  Ұ  ԰  ް                         jY  hEU UjY  hEU UjX  hEU UjW  hEU UjCW  hEU UjV  hEU Uj    h't UmH nH u jWV  hEU U	hEU 5hEU  j    hEU U 7Ư  ȯ      @  h  `            W            W            W            W                                                                                                 	  $If   gdEU   kdU  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   h  j        
  `            W            W            W            W                                                                                                 	  $If   gdEU   kd/X  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a             
            L  N      ı  Ʊ  ȱ  ұ  Ա  ֱ  ر                       "  $  &  (  <  >  @  J  L  N  P  R  f  h  j  þڢڗڌځv  j{]  hEU Uj\  hEU Uj(\  hEU Uj[  hEU Uj<[  hEU U	h8 5hB h  	h 5	h7P 5	h3 5	h~ 5h h 5	hEU 5hEU  j    h't UmH nH u j    hEU UjY  hEU U .
      N  Z  f      `            [            R            I            I            I            I                                   	  $If   gd3    h^hgdB    gd   kdnZ  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a       ֱ    &  N  `            W            W            W            W                                                                                                 	  $If   gdEU   kdZ  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   N  P  x    Ȳ    `            W            W            W            W                                                                                                 	  $If   gdEU   kd]  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   j  t  v  x  z                      Ĳ  Ʋ  Ȳ  ʲ  ޲                  
            0  2  4  >  @  B  D  X  Z  \  f  h  j  l                                ja  hEU Uj`  hEU Uj0`  hEU Uj_  hEU U	hEU 5j^  hEU Ujg^  hEU Uj]  hEU UhEU  j    hEU Uj    h't UmH nH u8      B  j    `            W            W            W            W                                                                                                 	  $If   gdEU   kdS_  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a             4  `            W            W            W            W                                                                                                 	  $If   gdEU   kda  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a                 ҳ  Գ  ֳ                  
      "  $  &  0  2  4  6  8  L  N  P  Z  \  ^  `  t  v  x                        Ĵ  ƴ  ȴ  Ҵ  ڹڴکڞړڈ   je  hEU Uj$e  hEU Ujd  hEU Uj8d  hEU U	hEU 5j[c  hEU Ujb  hEU Ujob  hEU UhEU  j    h't UmH nH u j    hEU Uja  hEU U 54  6  ^      ִ  `            W            W            W            W                                                                                                 	  $If   gdEU   kdc  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
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t  0                                                                                    4   4 
s a   x  z  |  ҵ  l  x      `            W            N            N            E            E            E                           	  $If   gdLIC    h^hgd    h^hgd3   kdOh  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a     ʶ  ̶      D  l              W            N            N            N            N                                                              	  $If   gdEU   kdh  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a  	  $If   gdLIC              
              2  4  6  @  B  D  F  Z  \  ^  h  j  l  n  p                              Է  ַ  ط                 
          &       jl  hEU UjHl  hEU Ujk  hEU Uj\k  hEU U	hEU 5jj  hEU Uj	j  hEU Uji  hEU UhEU  j    h't UmH nH u j    hEU U 9l  n          `            W            W            W            W                                                                                                 	  $If   gdEU   kdj  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a       8  `      `            W            W            W            W                                                                                                 	  $If   gdEU   kd4m  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   &  (  *  4  6  8  :  N  P  R  \  ^  `  b  v  x  z                          ȸ  ʸ  ̸  ָ  ظ  ڸ  ܸ                       &  (  *  ,  @  B  D  N  ڹڴکڞړڈ   j<q  hEU Ujp  hEU UjPp  hEU Ujo  hEU U	hEU 5jn  hEU Ujn  hEU Ujn  hEU UhEU  j    h't UmH nH u j    hEU Ujm  hEU U 5    ڸ    *  R  `            W            W            W            W                                                                                                 	  $If   gdEU   kdso  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   N  P  R  T  V  j  l  n  x  z  |  ~                      ȹ  ʹ  ̹  ι                  &  (  <  >  @  J  L  ^          ƺ  }                	h? 5	hYd 5j    h't 5UmH nH ujXt  hEU hEU 5U j    hEU 5U h91  j{s  hEU Ujs  hEU Ujr  hEU Uj    h't UmH nH u jr  hEU U	hEU 5hEU  j    hEU U .R  T  |    ̹    `            W            W            W            W                                                                                                 	  $If   gdEU   kdq  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a           غ  ں     `            ^            ^            U            U            U                                                                            	  $If   gdEU      kds  $$If   s             \ 3%"                                                                    
t  0                                                                                    4   4 
s a   ƺ  Ⱥ  ʺ  Ժ  ֺ                   "  $  &  :                              ,  4  6  J  t  v  x  z          溶{{{kjv  hEU hEU 5U h h8 6	h 6	hb 6h~ h8  h8  	hF 5	h8 5	h~ 5	huJ 5	h7P 5	h$M 5hEU  hF"G hEU 5jDu  hEU hEU 5U 	hEU 5j    h't 5UmH nH uj    hEU 5U jt  hEU hEU 5U*   "  $                                                            ~            ~            ~                                                                                                                                             	  $If   gd~    gd~   
& F gd~    gdLIC f  kdu  $$If   s              %" "                
t  0                                                4   4 
s a           6  v  s            j            j            j            j                                                                                                                                       	  $If   gd~   kd	v  $$If   s             F 3%"                                   L                
t  0                                                                        4   4 
s a   v  x    ȼ    q            h            h            h                                                                                                                                                    	  $If   gd~   kdvv  $$If   s             F 3%"                                   L                
t  0                                                                        4   4 
s a                 ļ  Ƽ  ȼ  ʼ  ޼                
            0  2  4  >  @  B  D  X  Z  \  f  h  l  n                  }                jz  hEU hEU 5U jy  hEU hEU 5U j0y  hEU hEU 5U jx  hEU hEU 5U jw  hEU hEU 5U j    h't 5UmH nH uj]w  hEU hEU 5U 	hEU 5	h8 5j    hEU 5U.      B  j  q            h            h            h                                                                                                                                                    	  $If   gdEU   kdIx  $$If   s             F 3%"                                   L                
t  0                                                                        4   4 
s a   j  l        q            h            h            h                                                                                                                                                    	  $If   gdEU   kdz  $$If   s             zF 3%"                                   L                
t  0                                                                        4   4 
s a                 ҽ  Խ  ֽ              $  &  (  *  ̾  ܾ            $  &  :  <  >  H  J  L  N  b  d  f  p  r  t  v    ҽ҇w                   j}  hEU hEU 5U j}  hEU hEU 5U h h0o 6	h 6	hb 6	h0o 5	h8 5	h7P 5	h3 5	h~ 5jy{  hEU hEU 5U 	hEU 5j    h't 5UmH nH uj    hEU 5U j{  hEU hEU 5U+        (  *  4  z    ʾ  q            l            g            _            l            V            V            V            V                           	  $If   gdVd   
& F gd~    gdLIC    gd~   kd{  $$If   s             F 3%"                                   L                
t  0                                                                        4   4 
s a   	ʾ  ̾           "  `            W            W            W            W            W                                                                                	  $If   gdVd   kd`|  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a   "  $  L  t    Ŀ  `            W            W            W            N                                                                               	  $If   gdVd 	  $If   gdEU   kd|  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a                         ¿  Ŀ  ƿ  ȿ  ܿ  ޿                          ,  .  0  :  <  >  @  T  V  X  b  d  ǤҔ҄tfǤjM  h91 hEU Uj׀  hEU hEU 5U ja  hEU hEU 5U j  hEU hEU 5U j    h't UmH nH u j~  h91 hEU Uh91 hEU  j    h91 hEU U	hEU 5j    h't 5UmH nH uj    hEU 5U jn~  hEU hEU 5U(Ŀ  ƿ      >  f  `            W            W            W            W                                                                                                 	  $If   gdEU   kdZ  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a   d  f  h  j  ~                                                      
       "  $  .  0  2  4  H  t                            j  hEU hEU 5U j    h't UmH nH u j  h91 hEU Uj    h91 hEU Uj@  hEU hEU 5U jʂ  hEU hEU 5U j    h't 5UmH nH ujT  hEU hEU 5U j    hEU 5U 	hEU 5h91 hEU (f  h          `            W            W            W            W                                                                                                 	  $If   gdEU   kdÁ  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a     
  2  Z      `            W            W            W            W                                                                                                 	  $If   gdEU   kd,  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a   H  J  L  V  X  Z  \  p  r  t  ~                                                             ҷ҄td j  hEU hEU 5U j  hEU hEU 5U j&  hEU hEU 5U j    h't UmH nH u j  h91 hEU Uh91 hEU  j    h91 hEU Uj  hEU hEU 5U 	hEU 5j    h't 5UmH nH uj    hEU 5U j3  hEU hEU 5U'        $  L  `            W            W            W            W                                                                                                 	  $If   gdEU   kd  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a      "  $  &  :  <  >  H  J  L  N  P  d  f  h  r  t  v  x                                                v                           j  h91 hEU Uj{  hEU hEU 5U j  hEU hEU 5U j    h't 5UmH nH uj  hEU hEU 5U j    h't UmH nH u j  h91 hEU Uh91 hEU  j    h91 hEU U	hEU 5j    hEU 5U)L  N  v        `            W            W            W            W                                                                                                 	  $If   gdEU   kd  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a         @  h    `            W            W            W            W                                                                                                 	  $If   gdEU   kdg  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a       
          .  0  2  <  >  @  B  V  X  Z  d  f  h  j  ~                          Ҳҧ{nfVn   ja  hEU hEU >*U hEU hEU >*j    hEU hEU >*U hLIC  	h8 5j    h't UmH nH u jZ  h91 hEU Uh91 hEU  j    h91 hEU Uj  hEU hEU 5U jn  hEU hEU 5U 	hEU 5j    h't 5UmH nH uj    hEU 5U j  hEU hEU 5U!              |  >  @  `            [            [            [            V            V            V            V            V                              gdLIC    gd~   kdЍ  $$If   s             \ 1!                  
                                                  
t  0                              ,"                                                    4   4 
s a   	                      n  z    :  B                                          
        `  b  d  ߻߻߲~z                              h.1  h 0J mH nH uhEU  
hEU 0J  j    hEU 0J UhO=  j    hO= Uh8 6CJ aJ hLIC 6CJ aJ h$M  hEU hLIC >*j׎  hEU hEU >*U hEU hEU >*hLIC  j    hEU hEU >*U j    h't >*UmH nH u *@  B                                  ^  `  b  d                                                                                                                                                                                                                                                                                                                                              $a$gdLIC   h]hgd    &`#$gd?       gdLIC  , 1h/ =!"#$%  , 1h/ =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                      t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           Y $$If     !v h5 L5L#v L:V s  
t      5 L4 
s j   D                                                                                                t   D                                                                     T e x t 1                           Y $$If     !v h5 L5L#v L:V s 
t      5 L4 
s G $$If     !v h5 "#v ":V l 
t    6  5 "t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           z $$If   !v h5 | #v | :V l 
t  0                                            65 "az $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                                     T e x t 1                           z $$If   !v h5 | #v | :V l 
t  0                                            65 "az $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                               e     C h e c k 1                         z $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                               e     C h e c k 1                         z $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                                     T e x t 1                           z $$If   !v h5 | #v | :V l 
t  0                                            65 "az $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           z $$If   !v h5 | #v | :V l 
t  0                                            65 "az $$If   !v h5 | #v | :V l 
t  0                                            65 "at   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           G $$If     !v h5 "#v ":V l 
t    6  5 " $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5X $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5Xt   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                            $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5Xt   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                            $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5Xt   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                            $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5Xt   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                            $$If     !v h5 5555T5X#v #v#v#v#vT#vX:V l 
t      5 5555T5Xu $$If     !v h5 55555#v :V s 
t      5 4 
s t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           u $$If     !v h5 55555#v :V s 
t      5 4 
s t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           u $$If     !v h5 55555#v :V s 
t      5 4 
s t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           u $$If     !v h5 55555#v :V s 
t      5 4 
s t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           t   D                                                                     T e x t 1                           u $$If     !v h5 55555#v :V s 
t      5 4 
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t      5 4 
s U $$If     !v h5 L5L#v L:V s 
t      5 L4 
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t      5 L4 
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t      5 L4 
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t      5 L4 
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t      5 L4 
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t    5 4 
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t    5 4 
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t    5 4 
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t    5 4 
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t  6@M   6   5 "e $$If     !v h5 555#v :V s 
t      5 4 
s e $$If     !v h5 555#v :V s 
t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 4 
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t      5 "4 
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t      5 5L4 
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t      5 5L4 
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t      5 5L4 
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t      5 5L4 
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t      5 5L4 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
s v   D                                                                     T e x t 2 5                           v   D                                                                     T e x t 2 6                           v   D                                                                     T e x t 2 7                           v   D                                                                     T e x t 2 8                            $$If     !v h5 5
55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
#v#v:V s 
t  ,"  5 5
554 
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55#v #v
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554 
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     0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                 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     0                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                 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     0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                        0                        0                        0                        0                        0                        0                        0                        0                    X 0 0                   X 0 0                   X 0 0                   X 0 0                   X 0 0                   X 0 0                   X 0 0               PX 0 0                  X 0 0                  @  0                  @  0                    X 00               X 0 0                     0                                    \M                 	                  $   $   $   $   $   $   $   $   $   '      F
    D  
    2  4  L  N  `  f  |          t"  :$  '  d*  +  -  "  ȥ  ԧ          ¯    j    Ҵ    &  N  ƺ        d  H         d               $   '   *   -   0   3   6   8   ;   =   @   D   G   H   I   L   O   Q   d   g   i   l   o   q   v   x   {                                                   b	        0    0  t    z      ^       D    "    f  V      <    N         t"  v)  `*  *  T+  j-  4    ʧ  Ψ    2  Ԫ  v          $  Ư  h  
    N      4  ִ  x    l      R         v    j    ʾ  "  Ŀ  f      L      @  d              !   "   #   %   &   (   )   +   ,   .   /   1   2   4   5   7   9   :   <   >   ?   A   B   C   E   F   J   K   M   N   P   e   f   h   j   k   m   n   p   r   s   t   u   w   y   z   |   }   ~                                                                                       b     +   7   =   ]   i   o   z                      	  -  9  ?  \  h  n                G  S  Y  e  q  w                    >  J  P  R  ^  d  f  r  x  z                                        	  	  	  	  	  '	  -	  0	  <	  B	  D	  P	  V	  X	  d	  j	  l	  x	  ~	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  	        #  %  1  7  :  F  L  N  Z  `  b  n  t  v                                                  #  )  ,  8  >  @  L  R  T  `  f  h  t  z  |                                          	                %  (  4  :  <  H  N  Q  ]  c  e  q  w                    M  Y  _  r  ~                #  +  ;  z        V  f            (  8  ^  n  B  N  T  V  b  h  j  v  |                      *  T  d              )  5  ;  N  Z  `          #  )  v            
      R  ^  d  v                                                   "  (  +  7  =  ?  K  Q  S  _  e  g  s  y  |                                          	              "  (  *  6  <  >  J  P  S  _  e  g  s  y  {                                          	        )  /  1  =  C  F  R  X  Z  f  l  n  z                          "  $  0  6  9  E  K  M  Y  _  a  m  s  u                                                  #  )  ,  8  >  @  L  R  T  `  f  h  t  z  }                        w                                                       %   +   -   9   ?   A   M   S   U   a   g   j   v   |   ~                                                         !  	!  $!  0!  6!  i!  u!  {!  !  !  !  M"  Y"  _"  a"  m"  s"  u"  "  "  "  "  "  "  "  "  "  "  "  "  "  "  "  "  "  "  "  #  #  #  #  #  #  #  #  #  #  #  #  #  #   $  $  $  $  $  $  ($  .$  0$  <$  B$  E$  Q$  W$  Y$  e$  k$  m$  y$  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  $  %  %  %  %  !%  #%  /%  5%  8%  D%  J%  L%  X%  ^%  `%  l%  r%  t%  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  %  &  
&  C'  FFFFFFFG$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFG$G$FG$G G G G FG G FFFFFFG G FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF                '   ! !  @                                @             H              0    (    	                    
                            (    	                    
          H   
      
  #                                     B    
        S              	   ?            C'            T    '   %    T e x t 1  C h e c k 1  T e x t 2  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  T e x t 3  C h e c k 6  C h e c k 7  T e x t 4  T e x t 5  T e x t 6  T e x t 7  T e x t 8  T e x t 9  C h e c k 8  C h e c k 9  T e x t 1 0  T e x t 1 1  T e x t 1 2  T e x t 1 3  T e x t 1 5  T e x t 3 1  T e x t 1 8  T e x t 1 9  T e x t 2 0  T e x t 2 1  T e x t 2 2  T e x t 2 3  T e x t 2 4  T e x t 2 5  T e x t 2 6  T e x t 2 7  T e x t 2 8  T e x t 2 9  T e x t 3 0 ,       z    V      '  ]  C  W  k          L      *  O    w    S  w          N"  b"  v"  #  %  %  D'                              	   
                                                                      !   "   #   $   >     &      g      9  o  U  i  }        +  e      <  a  *      e            `"  t"  "  #  %  &  D'      ۆ    ۆ  ue ۆ  2  	  #  D'                   #  D'               8      *urn:schemas-microsoft-com:office:smarttagsdate   LX
   10111213200757DayMonthYear    	                      	                       	                      &  &  &  &  &  &  &  &  &  &   '  '  '  '  D'                          =  @          s  v      f  i  f  t  &  &  &  &  &  &  &  &  &  &   '  '  '  '  D'   3  3  3  3  3  3  3  3                    +   >   ]   p   z                  
  -  @  \  o              G  Z  e  x                  >  Q  R  e  f  y  z                          	  	  	  	  .	  0	  C	  D	  W	  X	  k	  l	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
  
   
  #
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      $  %  8  :  M  N  a  b  u  v                                  *  ,  ?  @  S  T  g  h  {  |                            	          &  (  ;  <  O  Q  d  e  x              M  `  r              $  :  ;  z        V  g          (  9  ^  o  x  y  B  U  V  i  j  }                +  T  e                  )  <  =  =  N  a  h  h        *  v        
    R  e  v                                      )  +  >  ?  R  S  f  g  z  |                            	          )  *  =  >  Q  S  f  g  z  {                            	      0  1  D  F  Y  Z  m  n                      #  $  7  9  L  M  `  a  t  u                                  *  ,  ?  @  S  T  g  h  {  }                    w                                      ,   -   @   A   T   U   h   j   }   ~                                       
!  $!  7!  i!  |!  !  !  !  !  !  !  M"  `"  a"  t"  u"  "  "  "  "  "  "  "  "  "  "  "  "  #  #  #  #  #  #  #  #  #  #  #  #  $  $  $  $  /$  0$  C$  E$  X$  Y$  l$  m$  $  $  $  $  $  $  $  $  $  $  $  $  $  $  %  %  "%  #%  6%  8%  K%  L%  _%  `%  s%  t%  %  %  %  %  %  %  %  %  %  %  %  %  &  &  &  &  &  &  &  &  &  &  &  &   '  '  	'  '  '  '  @'  A'  D'                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              &  &  &  &  &  &  &  &  &  &   '  '  '  '  D'                  vJ  Ĉ[ f0Fc ^t9Ķ FPP$J ]*[F@ :bJ&* zx                          ^`o(    .                     
   ^`h    H    .                     
  pL p^p`Lh    H    .                      
  @ @^@`h    H    .                     
   ^`h    H    .                     
  L ^`Lh    H    .                      
   ^`h    H    .                     
   ^`h    H    .                     
  PL P^P`Lh    H    .               h        ^`5o(                  h         ^`5OJ QJ o( h    H                       
  pL p^p`Lh    H    .                      
  @ @^@`h    H    .                     
   ^`h    H    .                     
  L ^`Lh    H    .                      
   ^`h    H    .                     
   ^`h    H    .                     
  PL P^P`Lh    H    .              h      
  8 8^8`h    H     .             h      
   ^`h    H    .             h      
  	L 	^	`Lh    H    .              h      
   ^`h    H    .             h      
  x x^x`h    H    .             h      
  HL H^H`Lh    H    .              h      
   ^`h    H    .             h      
   ^`h    H    .             h      
  L ^`Lh    H    .                         \ ^`\o(    .                     
   ^`h    H    .                     
  pL p^p`Lh    H    .                      
  @ @^@`h    H    .                     
   ^`h    H    .                     
  L ^`Lh    H    .                      
   ^`h    H    .                     
   ^`h    H    .                     
  PL P^P`Lh    H    .                          ^`5o(    .                     
   ^`h    H    .                     
  pL p^p`Lh    H    .                      
  @ @^@`h    H    .                     
   ^`h    H    .                     
  L ^`Lh    H    .                      
   ^`h    H    .                     
   ^`h    H    .                     
  PL P^P`Lh    H    .              h      
   ^`h    H     .             h      
   ^`h    H    .             h      
  pL p^p`Lh    H    .              h      
  @ @^@`h    H    .             h      
   ^`h    H    .             h      
  L ^`Lh    H    .              h      
   ^`h    H    .             h      
   ^`h    H    .             h      
  PL P^P`Lh    H    .              h        ^`5h    H     .              h         ^`5h    H    .             h      
  pL p^p`Lh    H    .              h      
  @ @^@`h    H    .             h      
   ^`h    H    .             h      
  L ^`Lh    H    .              h      
   ^`h    H    .             h      
   ^`h    H    .             h      
  PL P^P`Lh    H    .                          ^`o(    .                     
   ^`h    H    .                     
  L ^`Lh    H    .                      
  
 
^
`h    H    .                     
  \ \^\`h    H    .                     
  ,L ,^,`Lh    H    .                      
   ^`h    H    .                     
   ^`h    H    .                     
  L ^`Lh    H    .    :b            f0            ]*[                        FPP            z            ^t9            v                                    	 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	 D 	 	 	 	 	 	 	 	 |4O 	 	 	 	 	 	 	 	  	 	 	 	 	 	 	 	 	 | 	 	 	 	 	 	 	 	 X 	 	 	 	 	 	 	 	                   3 x  Y VH O= } /| ^ xc 1 * [ ] ?  2  m! @9# |p' y' ) F* U* a- O0 91 A2 ch4 5 5 k/7 -9 |> ? ]A eA LIC sD P"F F"G uJ vqK lL $M oN ?O -,Q ?Q HnT oU L5V P(Y =jY \ <I] C_ ;` a <c Yd Vd Kdg (i 3l Q&l n -xn Awq Zt 't Rt -z I{ Yg} D~ ]U f \ ^ 4  nw \ `o   1 `: 8 r B ` Z  7 } b 7P <= 4 d V {7 G EU  F N  q  wV l F ~  0o  S J# 1 U # 4   ~ v- B ~O f, z Y .1     #   ?   q   r                     A  B  C  D  p  q  r  s                                b  g  t                    !  =  >  R  f  z                	  	  /	  0	  D	  X	  l	  	  	  	  	  	  	  	  	  
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    %  9  :  N  b  v                    +  ,  @  T  h  |                	      A  K  c  d          '  (  <  P  Q  e  y  z                A  B  V  j  ~                          %  &  >  X  x                      *  +  ?  S  g  {  |                	      S  Y  _  t                  *  >  R  S  g  {                  	    1  E  F  Z  n                        $  8  9  M  a  u                      +  ,  @  T  h  |  }            G  M  S  h  v  w                         -   A   U   i   j   ~                        !  !  !  !  !  !  !  !  "  "  "  ,"  L"  M"  a"  u"  "  "  "  "  "  "  "  "  #  #  &#  +#  N#  S#  v#  w#  #  #  #  #  #  #  #  #  #  #  $  $  0$  D$  E$  Y$  m$  $  $  $  $  $  $  $  $  $  %  #%  7%  8%  L%  `%  t%  %  %  %  %  %  %  %  D'                                                                 "                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              @  8   =   d   8      8                              
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per your request        Stephanie.L.Roettgen@dss.mo.gov       Roettgen, Stephanie L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r   s   t   u   v   w   x   y   z   {   |   }   ~                                                                                                                                                                                                                                                                                                                                                                                                                   	  
                                               !  "  #  $  %  &  '  (  )  *  +  ,  -  .  /  0  1  2  3  4  5  6  7  8  9  :  ;  <  =  ?  @  A  B  C  D  E  G  H  I  J  K  L  M  R  R o o t   E n t r y                                                 	           F            BT         D a t a                                                         
                                        M      1 T a b l e                                                                                                         W o r d D o c u m e n t                                                                                        \R      S u m m a r y I n f o r m a t i o n                           (                                     >          D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        F          C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                           