04-004, Department of Health and Human Services
1.
DATE ISSUED MoIDaylYr 12. CFDA NO.
09/01/041 93.008
SUPERSEDES AWARD NOTICE dated N/A
Except that any
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
OFFICE OF PUBLIC HEALTH AND SCIENCE
OFFICE OF THE SURGEON GENERAL
ROCKVILLE, MARYLAND 20852
NOTICE OF GRANT AWARD
AUTHORIZATION (Legislation/Regulation)
I
..j .
.i
3.
additions or restrictions previOusly imposed remain in effect unless speCifically rescinded
4.
GRANT NO.
MRCSG030083-02-0
Formerly:
US2SG03041
5.ADMINISTRATIVE CODES
MPU-S2
6.
PROJECT PERIOD
FROM
BUDGET PERIOD
FROM
MoIDaylYr
09/30/03!rHROUGH
MoIDaylYr
09/30/041 THROUGH
MoIDaylYr
09/29/06
MEDICAL RESERVE CORPS
TITLE XVII, SECTION 1701 (e) (1),
PUBLIC HEALTH SERVICE ACT AS AMENDED
8.
TITLE OF PROJECT (OR PROGRAM)
MoIDaylYr
09/29/05
MEDICAL RESERVE CORPS DEMONSTRATION GRANT PROGRAM
7.
9 GRANTEE NAME AND ADDRESS .,.
a. CITY OF CUPERTINO MARSHA HOVEY
EMERGENCY COORDINATOR
b. OFFICE OF EMERGENCY SERVICES CITY OF CUPERTINO
OFFICE OF EMERGENCY SERVICES
c. 10300 TORRE AVENUE 10300 TORRE AVENUE
CUPERTINO, SANTA CLARA, CA 95014
d. CUPERTINO, SANTA CLARA, CA 95014
ll. . (Exc udes PHS Direct Asslstancel TlJWilI III ,XVII, SECTIUN 1 fUfld) (1 I,
I PHS Grant Funds Only a. Amount of PHS Financial Assistance (from Item 11.u.) $50,000
II Total project costs including grant funds and all other I b. Less Unobligated Balance from Prior Budget Periods
financial participation. (Select one and place NUMERAL in box.) c. Less Cumulative Prior Award(s) This Budget Period
a. Salaries and Wages... $20,800 d. AMOUNT OF FINANCIAL ASSISTANCE THIS ACTION I $50,000 I
b. Fringe Benefits... 0 13.RECOMMENDED FUTURE SUPPORT (SUBJECT TO THE AVAILABILITY OF FUNDS AND
c. Total Personnel Costs... $20,800 SATISFACTORY PROGRESS OF THE PROJECT):
d. Consultant Costs...... 0 YEAR TOTAL COSTS/STIPENDS YEAR TOTAL COSTS/STIPENDS
e. Equipment..... 13,270 a.03 50,000 d.
f. Supplies... 7,330 b. e.
g. Travel... . 5,100 c. f.
h. Patient Care-Inpatlent... 0 14. APPROVED DIRECT ASSISTANCE BUDGET (IN LIEU OF CASH)
i. -Oulpatient... 0 a. Amount of PHS Direct Assistance
j. Alterations and Renovations 0 b. Less Unobligated Balance from Prior Budget Periods
k. Other..... 3,500 c. Less Cumulative Prior Award(s) This Budget Period
I. ConsortiurmiConlractual Costs d. AMOUNT OF DIRECT ASSISTANCE THIS ACTION I I
m. Trainee Related Expenses... 0 15. PROGRAM INCOME SUBJECT TO 45CFR PART 74, SUBPART F, 01
n. Trainee Stipends... 0 SHALL BE USED IN ACCORD WITH ONE OF THE FOLLOWING ALTERNATIVES:
o. Trainee Tuition and Fees... 0 (Select One and Place LETTER in box.)
p. Trainee TraveL ........................ 0 a. DEDUCTION D
b. ADDITIONAL COSTS
q. TOTAL DIRECT COSTS $50,000 c. MATCHING
r. INDIRECT COSTS-(Rate 0.00% d. OTHER RESEARCH (Add/Deduct Option)
of S&W/TADC) 0 e. OTHER (See REMARKS)
16. THIS AWARD IS BASED ON AN APPLICATION SUBMITTED TO AND AS APPROVED
s. TOTAL APPROVED BUDGET $50,000 BY, THE PHS ON THE ABOVE TITLED PROJECT AND IS SUBJECT TO THE TERMS
AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING:
t. Federal Share... $50,000 a. The grant program legislation ciled above.
u. Non-Federal Share.... b. The grant program regulation cited above.
'Musl meel all matching requirements. c. This award notice including terms and conditions, if any, noted below under Remarks.
Subject to adjustment in accordance with PHS policy. d. PHS Grants Policy Slatement including addenda in effect as of the beginning date of the budget period
e. 45 CFR Part 74 and 45 CFR Part 92 as applicable.
In the event there are conflicting or otherwise inconsistent policies applicable to the grant,
the above order of precedence shall prevail. Acceptance of the grant terms and conditions
is acknowledoed bv the arantee when funds are drawn or otherwise obtained from the orant navment svstem.
REMARKS (Other Terms & Condilions Attached I X Yes I I No
Due to an administrative change the Grant Number has been changed to MRCSG030083 (Block 4. Grant Number).
The Document Number (Line 20.) remains the same. Please use your document number when contacting the
Payment Management System for issues relating to your account.
PHS GRANTS MANAGEMENT OFFICER
(Name-Typed/Print)
(Title)
17.0BJ.CLASS
Karen Cam bell, Grants Mana ement Officer, OPHS
46027368A 1 19.L1ST NO SG2-04-08
FV-CAN
4-1990790
DOCUMENT NO
b. U2SG03041 A
b.
b.
ADMINISTRATIVE CODE
AMT_ACTION FIN_ASST
'd. $50,000
d.
d.
AMT_ACTION DfR. ASST
20.a.
21.a.
22.a.
PHS-5152.' (rev 5192)
c. MPU-S2
e.
e.
e.
c.
c.
NOTICE OF GRANT AWARD (Continuation Sheet)
PAGE 2 of 4
DATE ISSUED
GRANT NO, MRCSG030083-02-0
ITEM NO.
SPECIAL CONDITIONS:
(If applicable)
1. All drawdown Payment Management System (PMS) requests must have the prior approval of the Grants
Management Officer. By the 20th of each month, for the upcoming month, or no less than 10 days prior
to the need for funds, submit an original signed PMS-270 form for anticipated expenditures along with
documentation to substantiate the request for funds. The original PMS-270 drawdown request must be sent
to the Grants Management "contact." Please refer to the "Contacts" section of this award for the appropriate
contact name and address.
(Additional conditions if applicable.)
Failure to comply with the above special condition(s) may result in a disallowance of funds, a
drawdown restriction, or denial of future funding.
(If con dition (s) refer to a drawdown restriction remove the reference to a drawdown restriction from
'Pailure to comply......... ,.
SPECIAL REMARKS:
(Remarks pertaining specifically to the Grantee.)
1. Indirect costs (11r.)have been computed at the provisional rate of 8% of salaries and wages pending
establishment of a rate with DHHS Division of Cost Allocation. Failure to establish a rate prior to the
submission of the Financial Status Report may result in the disallowance of these funds.
(Special remark for all grantees. )
2. Grantee must obtain prior approval from the GMO for any change in the Project Director of Project
Coordinator including replacement, absence, or reduction in the level of participation. The GMO must be
notified no later than 30 days before the expected date of departure or change in participation level. A
resume must be submitted for approval for any replacement.
STANDARD REMARKS:
1. Requests that require prior approval from the awarding office (Chapter 8, Grants Policy) must be
submitted in writing to the Grants Management Officer. Only responses signed by the Grants Management
Officer are to be considered valid. Grantees who take action on the basis of responses from other officials
do so at their own risk. Such responses will not be considered binding by or upon the Office of Minority
Health.
Db
PHS-SlS2-2 (5/92)
NOTICE OF GRANT AWARD (Continuation Sheet)
PAGE 3 of4
DATE ISSUED
GRANT NO. MRCSG030083-02-0
ITEM NO.
2. Responses to reporting requirements, conditions, and requests for postaward amendments must be mailed
to the attention and address of the Grants Management contact indicated above. All correspondence should
include the Federal grant number (item 4 on page 1 of this document) and requires the signature ofan
authorized business official and/or the project director. Failure to follow this guidance will result in a delay
in responding to your correspondence.
3. The HHS Appropriations Act requires that to the greatest extent practicable, all equipment and products
purchased with funds made available under this award should be American-made.
4. The HHS Appropriations Act requires that when issuing statements, press releases, requests for
proposals, bid solicitations, and other documents describing projects or programs funded in whole or in part
with Federal money shall clearly state the percentage and dollar amount of the total costs of the program or
project which will be financed with Federal money and the percentage and dollar amount of the total costs of
the project or program that will be financed by nongovernmental sources.
5. A notice in response to the President's Welfare-to-Work Initiative was published in the Federal Register
on 5/16/97. This initiative is designed to facilitate and encourage grantees to hire welfare recipients and to
provide additional training and/or mentoring as needed. The text of the notice is available electronically on
the OMB home page at http://www.whitehouse.gov/wh/eop/omb.
6. Payments under this award will be made available through the DHHS Payment Management System
(PMS). PMS is administered by the Division of Payment Management, Financial Management Services,
Program Support Center, which will forward instructions for obtaining payments. Inquiries regarding
payment should be directed to:
Payment Management, DHHS, P.O. Box 6021, Rockville, MD 20852
Telephone Number: 301-443-1660
7. The DHHS Inspector General maintains a toll-free hotline for receiving information concerning fraud,
waste, or abuse under grants and cooperative agreements. Such reports are kept confidential and callers may
decline to give their names if they choose to remain anonymous.
Office of Inspector General, Department of Health and Human Services, Attn: HOTLINE
330 Independence Ave., SW, Room 5140 Cohen Building, Washington, DC 20201
e-mail Htips@os.dhhs.gov 1-800-447-8477 (1-800-HHS-TIPS)
PHS-5152-2 (5/92)
Db
NOTICE OF GRANT AWARD (Continuation Sheet)
PAGE 4 of4
DATE ISSUED
GRANT NO. MRCSG030083-02-0
ITEM NO.
REPORTING REQUIREMENTS:
(1) Financial Status Report SF-269/long form (attached) is due within 90 days after expiration of the budget
period.
(2) An A-133 audit, as required by OMB Circular A-133, must be mailed to the following: Federal Audit
Clearinghouse, Bureau of the Census, 1201 E. 10th Street, Jeffersonville, IN 47132.
A copy of the audit must be sent to: Office of Minority Health, Rockwall II Bldg., 5515 Security
Lane, Suite 1000, Rockville, MD 20852.
The audits are due within 30 days of receipt from the auditor or within 9 months of the end of the fiscal year,
whichever occurs first.
Submission of audit reports in accordance with the procedures established in OMB Circular A-133 is
required by the Single Audit Act Amendments of 1996 (P.L. 104-156). Failure to comply with this
requirement will result in deferral or restrictions of future funding decisions.
CONTACTS:
Grants Management
For assistance on grants administration issues please contact: , Grants Management Specialist, at
(301) 594- , FAX (301) 443-8280, Internet @osophs.dhhs.gov or Office of Minority Health Office
of Minority Health, Rockwall II Bldg., 5515 Security Lane, Suite 1000, Rockville, MD 20852.
Proiect Officer:
For assistance on programmatic issues please contact , Project Officer, at
(301) 594-0769, FAX (301) 443-5655, Internet (CUosouhs.dhhs.20V or Office of Minority Health,
Rockwall IT Bldg., 5515 Security Lane, Suite 1000, Rockville, MD 20852.
PHS-S1S2-2 (Sin)
Dk,
,.1o\lIVrCI:
.? .i#
(. ~ DEPARTMENT OF HEALTH &. HUMAN SERVICES
+~"'..ak"-
Public Health Service
November 1 0, 2003
Office of the Surgeon General
Rockville MD 20857
medica~1 ...
reserve
corps
Marsha Hovey
City of Cupertino
10300 Torre Ave
Cupertino, CA 95014-3202
Dear MRC Proj ect Director:
Please accept my congratulations on being selected to receive a Medical Reserve Corps
Grant Award. As you may already know, this Grant is funded through the Medical Reserve
Corps (MRC) program, which is headquartered in the Office of the U.S. Surgeon General.
The MRC is a component of Citizen Corps, which in turn is part of the President's National
Volunteer Initiative, USA Freedom Corps. Your community's contributions will make a
great difference to the safety and well-being of your local citizens. For that, we thank you.
Enclosed with this letter you will find an "Administrative Summary." It contains comments
from the panel of independent experts who reviewed your grant application. You may find
their comments useful as you move forward with developing your MRC. Additional
guidance documents, such as "The Guide for Local Leaders" and other information, can be
found on the MRC web site at www.medicalreservecorps.gOv.
Upon accepting this award, you will be entering into a cooperative agreement with the Office
of the Surgeon General. The nature of this cooperative relationship is described in an
information document (enclosed). It also contains contact information, including where to
call to access your approved funding. It tells you how to get in touch with the Office of
Grants Management. They can answer any financial or regulation-compliance questions you
might have. For questions concerning your MRC's performance or for communicating
achievements, please call or e-mail the MRC program staff and technical assistance team at
(301)443-4951. They will be happy to help in any way they can.
We look forward to a productive and collaborative relationship with you in the coming years.
Above all, I want to wish you the very best success with your MRC initiative.
Sincerely,
. /) ~/ P / J
!~ #/~
Richard H. Carmona, M.D., M.P.H., F.A.C.S.
V ADM, USPHS
United States Surgeon General
Enclosures
1. Administrative Summary
2. Information Document
1.
DATt ISSUED Mo/DaylYr /2. CFDA NO.
09/30/03 93.008
SUPERSEDES AWARD NOTICE dated N/A
Excepllhat any
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
OFFICE OF PUBLIC HEALTH AND SCIENCE
OFFICE OF THE SURGEON GENERAL
ROCKVILLE, MARYLAND 20852
NOTICE OF GRANT AWARD
AUTHORIZATION (Legislation/Regulation)
3.
additions or restrictions previously imposed remain in effect unless specifically rescinded.
4.
GRANT NO.
US2SG03041-0 1-0
5.ADMINISTRATIVE CODES
MPU-S2
6.
Formerly:
SGMC-03-074
PROJECT PERIOD
FROM
BUDGET PERIOD
FROM
Mo/DaylYr
09/30/031 THROUGH
Mo/DaylYr
09/30/031 THROUGH
Mo/DaylYr
09/29/06
MEDICAL RESERVE CORPS
TITLE XVII, SECTION 1701(e) (1),
PUBLIC HEALTH SERVICE ACT AS AMENDED
7.
8.
TITLE OF PROJECT (OR PROGRAM)
MoIDaylYr
09/29/04
CITY OF CUPERTINO MEDICAL RESERVE CORPS
9. GRANTEE NAME AND ADDRESS I .IN<';II-'AL INVt:::; IIGA TUK)
a. CITY OF CUPERTINO MARSHA HOVEY
EMERGENCY COORDINATOR
b. OFFICE OF EMERGENCY SERVICES CITY OF CUPERTINO
OFFICE OF EMERGENCY SERVICES
c. 10300 TORRE AVENUE 10300 TORRE AVUNUE
CUPERTINO, SANTA CLARA, CA 95014
d. CUPERTINO, SANTA CLARA, CA 95014
11. '" -KC V"U "Uu"",, I (Excludes PHS Direct "ssistance) 12.AWI iIL"XVI, IUN 1 07(d) 1),
I PHS Grant Funds Only a. Amount of PHS Financial Assistance (from Item 11.u.) $50,000
II Total project costs including grant funds and all other I b. Less Unobligated Balance from Pnor Budget Penods
financial participation. (Select one and place NUMERAL in box.) c. Less Cumulative Prior Award(s) This Budget Period
a. Salanes and Wages... $14,500 d. AMOUNT OF FINANCIAL ASSISTANCE THIS ACTION r $50,000 I
b. Fringe Benefits... 0 13.RECOMMENDED FUTURE SUPPORT (SUBJECT TO THE AVAILABILITY OF FUNDS AND
c. Total Personnel Costs.. $14,500 SATISFACTORY PROGRESS OF THE PROJECT):
d. Consultant Costs... 0 YEAR TOTAL COSTS/STIPENDS YEAR TOTAL COSTS/STIPENDS
e. Equipment... 18,345 a.02 50,000 d.
f. Supplies... 9,325 b.03 50,000 e.
g. Travel... 2,330 c. f.
h. Patient Care-Inpatient... 0 14. APPROVED DIRECT ASSISTANCE BUDGET (IN LIEU OF CASH)
i. -Outpatient... 0 a. Amount of PHS Direct Assistance
j. Alterations and Renovatior .. 0 b. Less Unobligated Balance from Pnor Budget Pen ods
k. Other... 0 c. Less Cumulative Pnor Award(s) This Budget Penod
I. ConsortiurmlContractual C . 5,500 d. AMOUNT OF DIRECT ASSISTANCE THIS ACTION I I
m. Trainee Related Expenses . 0 15. PROGRAM INCOME SUBJECT TO 45CFR PART 74, SUBPART F, OR
n. Trainee Stipends.... 0 SHALL BE USED IN ACCORD WITH ONE OF THE FOLLOWING ALTERNATIVES:
o. Trainee Tuition and Fees... 0 (Select One and Place LETTER in box.)
p. Trainee Travel .................. ........................ 0 a. DEDUCTION D
b. ADDITIONAL COSTS
q. TOTAL DIRECT COSTS $50,000 c. MATCHING
r. INDIRECT COSTS-IRate 0.00% d. OTHER RESEARCH (Add/Deduct Option)
of S&WfTADC) 0 e. OTHER (See REMARKS)
16. THIS AWARD IS BASED ON AN APPLICATION SUBMITTED TO AND AS APPROVED
s. TOTAL APPROVED BUDGET $50,000 BY, THE PHS ON THE ABOVE TITLED PROJECT AND IS SUBJECT TO THE TERMS
AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING:
t. Federal Share... $50,000 a. The grant program legislation cited above.
u. Non-Federal Share'... b. The grant program regulation cited above.
*Must meet aU matching requirements. c. This award notice including terms and conditions, if any, noted below under Remarks.
Subject to adjustment in accordance with PHS policy. d. PHS Grants Policy Statement including addenda in effect as of the beginning date of the budget period
e. 45 CFR Part 74 and 45 CFR Part 92 as applicable.
In the event there are conflicting or otherwise inconsistent policies applicable to the grant,
the above order of precedence shall prevail. Acceptance of the grant terms and conditions
Is acknowledaed bv the orantee when funds are drawn or otherwise obtained from the orant Davment sYStem.
REMARKS (Other Terms & Conditions AttaChed I X Yes I INo
PHS GRANTS MANAGEMENT OFFICER:
FY-CAN
3-1990790
(Name.TypedlPrinl)
(Tille)
17.0BJ.CLASS
bell, Grants Mana ement Officer, OPHS
19.L1ST NO SG2-03-06
20.a.
21.a.
22.a.
PHS-5152-1 (rev. 5/92)
DOCUMENT NO.
b. U2SG03041A
b.
b.
c. MPU-S2
AMT.ACTION FIN.ASST.
'd. $50,000
d.
d.
AMTACTlON DIR. ASST
c.
c.
e.
e.
e.
NOTICE OF GRANT AWARD (Continuation Sheet)
PAGE 2 of 4
DATE ISSUED 0 9/3 0 / 0 3
GRANT NO. US2SG03041-01-0
ITEM NO.
SPECIAL CONDITIONS:
NONE.
SPECIAL TERMS & REQUIREMENTS:
1. Grantees must obtain prior approval from t11e Grants ]'Vf;lll;lgement Officer (G1\fO) for ;111Y ch;lIlge in the
Project Director or Project Coordinator including replacement, absence, or reduction in the level of
participation. The GMO must be notified no later than 30 days before the expected date of lL..'parturc or
change in participation level. A resume must be submitted for approval for any replacement.
STANDARD TERMS:
1. Requests that require prior approval from the awarding office (See Chapter 8, PHS Grants Policy
Statement) must be submitted in writing to the GMO. Only responses signed by the GMO are to be
considered valid. Grantees who take action on the basis of responses from other officials do so at their own
risk. Such responses will not be considered binding by or upon the Office of Minority Health.
2. Responses to reporting requirements, conditions, and requests for postaward amendments must be mailed
to the attention and address of the Grants Management Specialist indicated below in "Contacts". All
correspondence should include the Federal grant number (item 4 on page 1 ofthis document) and requires
the signature of an authorized business official and/or the project director. Failure to follow this guidance
will result in a delay in responding to your correspondence.
3. The HHS Appropriations Act requires that, to the greatest extent practicable, all equipment and products
purchased with funds made available under this award should be American-made.
4. The HHS Appropriations Act requires that, when issuing statements, press releases, requests for
proposals, bid solicitations, and other documents describing projects or programs funded in whole or in part
with Federal money shall clearly state the percentage and dollar amount of the total costs of the program or
project which will be financed with Federal money and the percentage and dollar amount ofthe total costs of
the project or program that will be financed by nongovernmental sources.
5. A notice in response to the President's Welfare-to-Work Initiative was published in the Federal Register
on 5/16/97. This initiative is designed to facilitate and encourage grantees to hire welfare recipients and to
provide additional training and/or mentoring as needed. The text of the notice is available electronically on
the OMB home page at http://www.whitehouse.gov/wh/eop/omb.
PHS-5152-2(5/92)
Dk:
NOTICE OF GRANT AWARD (Colllilll/alioll Sheel)
PAGE 3 of 4
DATE ISSUED
09/30/03
GRANT NO. US2SG0304l-0l-0
ITEM NO.
REPORTING REQUIREMENTS:
(1) Financial Status Report SF -269/long form (attached) is due within 90 days after expiration of the budget
period.
(2) An A-133 audit, as required by OMB Circular A-133, must bc mailed to the following: Federal Audit
Clearinghouse, Burcau o[the CcnsLls, 1201 E. lath Street, Jcffer:.:;umille, I~ -+7132.
A wVy of the audH must be sent tu: OHit:e of l'ublit: Health aud St:ieuce, OHit:e of Grants
Management, 1101 Wootton Parkway, Suite 550, Tower Building, Rockville, Maryland 20852.
The audits are due within 30 days of receipt from the auditor or within 9 months of the end of the fiscal year,
whichever occurs first.
Submission of audit reports in accordance with the procedures established in OMB Circular A-I33 is
required by the Single Audit Act Amendments of 1996 (P.L. 104-156). Failure to comply with this
requirement will result in deferral or restrictions of future funding decisions.
Grants Management
For assistance on grants administration issues please contact: DeWayne Wynn, Grants Management
Specialist, at (301) 594-9417, FAX (301) 594-9399, Internet DWynn@osophs.dhhs.gov or Office of Public
Health and Science, Office of Grants Management, 1101 Wootton Parkway, Suite 550, Tower Building,
Rockville, Maryland 20852.
Proiect Officer:
For assistance on programmatic issues please contact Captain Mary Lambert, Project Officer, at
(301) 443-2528, FAX (301) 443-3574, Internet MLambert@osophs.dhhs.~ov or Office of Surgeon General,
Office of Public Health and Science, U.S. Department of Health and Human Services, Room 18-Cl4, 5600
Fishers Lane, Rockville, MD 20857.
CONTACTS:
Funds:
Payments under this award will be made available through the DHHS Payment Management System (PMS).
PMS and is administered by the Division of Payment Management, Financial Management Services,
Program Support Center, which will forward instructions for obtaining payments. Inquiries regarding
payment should be directed to:
Payment Management, DHHS, P.O. Box 6021, Rockville, MD 20852
Telephone Number: 301-443-1660
PHS-5152-2(5/92)
Dk:
NOTICE OF GRANT AWARD (Colllilll/llliOIl Sheet)
PAGE 4 of 4
DATE ISSUED
09/30/03
GRANT NO. US2SG0304l-01-0
ITEM NO.
Fraud, Abuse, and Waste:
The DHHS Inspector General maintains a toll-free hotline for receiving information concerning fraud,
waste, or abuse under grants and cooperative agreements. Such reports are kept confidential and callers may
decline to give their names if they choose to remain anonymous.
Office of Inspector General, Dep,lItl11ent uflIc,dth and !Tull1an Senice.;, .\Un: 110TL1.'\[
330 Indcpcl1l1cnce Ave., SW, Roo11151-+0 Cohen Building, Washingtoll, DC 20201
, .:1 '.." .[ \.'00 I'~" 1-:-' (1 "'() ""C' TI"S")
\"'-lll,li ""{""'.' .'".dd,L."," -0 --t-fl"u-r,; -2llJ -IiI L)- l t .
PHS-5152-2(5/92)
Dk: