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This Agreement is made this day of , by and between
Daughters of Israel
(“Facility”), Resident and/or Resident’s Representative
who each agree to the following terms and conditions to provide for the care of
the Resident:
I.
SERVICES:
A.
PROVISION OF SERVICES BY THE FACILITY:
The Facility agrees to admit the
Resident on
to provide basic medical and nursing care,
rehabilitation, dietary care, room and board, laundry, social work services,
activities, housekeeping and maintenance.
B.
ARRANGEMENT FOR THE PROVISION OF SERVICES:
The Facility will arrange for the
provision of medical, dental, therapeutic, podiatry, diagnostic, vision care,
room and board, laundry, and other health care or services, as well as
medication which must be supplied by the Facility’s contracted pharmacy, and other
treatments or aids a physician may order. The Facility is not responsible for
payment of such services unless such services are the responsibility of the
Facility under the government’s prospective payment, consolidated billing or
other governmental program requirements for qualified Residents.
The Resident and/or the Resident’s
Representative who has legal access to the Resident’s income or resources
agrees and acknowledges that he/she will be responsible for the payment to the
Facility and/or the provider of such services from the Resident’s income or
resources for any charges for the provision of such services which are not paid
by Medicare, Medicaid or other third party. The Resident and/or Resident’s Representative
agree that all such payments shall be made within thirty (30) days of receipt
of the Facility’s or Provider’s Bill.
The Resident must obtain all
pharmaceutical services, including medications, from the Facility’s contracted
pharmacy. Those services must be provided under the Resident’s Medicare Drug
Plan or other comparable drug plan if the Resident is eligible.
C.
FINANCIAL
ASSISTANCE PROGRAM:
Nothing in this Agreement
shall eliminate, refuse, or deny the Resident’s or the Facility’s rights to participate
in any financial assistance program sponsored or underwritten by any
governmental agency, whether Federal, State, County or Municipal, or a
combination thereof.
D.
REFUNDS:
The Facility will make refunds in
accordance with established policy of the Facility. Upon discharge or death of the Resident or
termination of this Agreement, the Resident’s outstanding debts due the
Facility, including but not limited to room fees, fees for additional services,
Medicaid payments, funeral expenses, etc. shall be paid by the Resident’s
income or resources currently held by the Facility in the Resident’s
account. Fees will be pro-rated on a
monthly basis for the month in which discharge, death or termination occurred
and any excess monies in the Resident’s account will be refunded to the
Resident and/or the Resident’s Representative or responsible party indicated on
the Resident’s records at the time of admission to the Facility or to the
Executor/Executrix of the Resident’s estate if there is no Representative or
responsible party. Refunds will be made within
sixty (60) days following the date of discharge, death or termination.
E. MEALS:
The Facility will provide three (3)
meals a day, and between-meal and bedtime snacks. Therapeutic diets will be
provided upon the written order of the Resident’s physician. All meals are
prepared under Rabbinical supervision. Any food brought into the Facility must
meet our Kashruth standards. A list of local Kosher establishments that meet
our Kashruth standards is provided in “Things to Know About Daily Life at
Daughters of Israel” Handbook.
F.
LODGING:
1. The Facility is a non-smoking Facility.
2. The Facility has the right
to determine the accommodations in which the Resident will live based upon a
professional assessment of the Resident’s needs.
3.
The
Facility shall endeavor to maintain the Resident in the room to which he or she
was originally assigned as long as his or her clinical condition remains
substantially the same. However, the Facility reserves the right to change a
Resident’s room, section of the Facility or a Resident’s roommate within the
Facility upon prior notice of such a change and the Resident’s and/or Resident’s
Representative’s right to an informal hearing if required by law.
The Resident and/or Resident’s
Representative agree to cooperate with any transfer within the facility undertaken
in accordance with this Agreement. The Resident and/or Resident’s
Representative consent to the assessment and reassessment of his or her
capabilities in order to determine his or her appropriate placement in the
facility.
4. Insurance coverage on the
Resident’s personal property is not provided by the Facility. If the
Resident and/or Resident’s Representative desire insurance, it is his or her responsibility
to obtain it. Resident’s valuables and monies may be stored in the Facility’s
safe if the safe has room to accommodate them. The Facility recommends that the
Resident not have significant amounts of cash on hand or in his or her room. The
Facility recommends that Residents not keep valuable items, i.e. jewelry,
collectible items, etc., at the Facility.
G.
TRANSFERS AND DISCHARGE:
1. The Facility may discharge or transfer the Resident from the
Facility, upon prior notice to the Resident’s next of kin, guardian and/or
Resident’s Representative, of at least thirty (30) days (except for emergency situations)
or such other time period as is legally required, in the following instances:
a.
For
medical reasons;
b.
To
protect the Resident’s safety or welfare and the Resident’s needs cannot be met
in the facility;
c.
To
protect the safety or welfare of others in the Facility;
d.
The
Resident and/or Resident’s Representative has failed after reasonable and
appropriate notice, to pay from the Resident’s income and resources for the
Facility’s services or have these services paid for by Medicare, Medicaid or
other government or private funding source;
e.
In
order to comply with the Resident’s clearly expressed and documented choice;
f.
To
comply with the Resident’s Advance Directive, in accordance with the New Jersey
Advance Directives for Health Care Act;
g.
When
it becomes known that Resident and/or Resident’s Representative have falsified
information on Application Form and such falsification results in nonpayment
for Facility’s services after reasonable and appropriate notice to the Resident
and/or Resident’s Representative from the Facility;
h.
The
Resident’s health has improved sufficiently so that he/she no longer needs the
services provided by the Facility; or
i.
The
Facility ceases to operate.
2. In the case of an emergency, notification of
the Resident’s physician, and/or next of kin, guardian and/or Resident’s
Representative will be provided, if possible, consistent with the severity of
the emergency situation.
3. When the Resident is transferred to a hospital or other health
care facility, the Facility’s bed hold policy becomes effective. Resident and/or
Resident’s Representative acknowledge having received a copy of the bed hold policy
as outlined in the “Things to Know About Daily Life at Daughters of Israel”
Handbook.
4. Resident and/or Resident’s Representative consent to the
Facility’s right to sign applications and any other necessary documents to
admit Resident to any suitable facility for the care of the Resident as
determined by the Facility’s Medical Staff. Applicant agrees (i) to assume full
responsibility for any and all costs of the facility to which he or she is
transferred and (ii) that the Facility shall have no medical or financial
responsibility in connection with such transfer.
H.
RELATIONSHIP WITH
PHYSICIANS:
1. The Resident and/or Resident’s Representative agree and consent
that the Resident will receive medical tests, medication and treatment as
prescribed by the Facility’s physician’s orders and therefore relieve the
Facility of any liability in following the physician’s directions. The Resident
and/or Resident’s Representative also agree to cooperate in allowing the
Facility to arrange for covering attending and consulting physicians.
2. The Facility will arrange, at the Resident’s and/or Resident’s
Representative’s expense, for transfer of the Resident to the hospital, when
ordered by the Resident’s physician. The Resident and/or Resident’s Representative
agree (i) to assume full responsibility for the cost of such care and/or
treatment and (ii) that the Facility shall have no financial or medical
responsibility in connection with such a hospitalization.
II.
FINANCIAL ARRANGEMENTS:
A. FEES:
1. Basic Charges: If the Resident is a private pay resident (payment
is made from the Resident’s income or resources, not from Medicare,
Medicaid, Long Term Care or other insurance), the Resident and/or Resident’s Representative
agree to pay on the first day of each month the Facility’s current basic daily
per diem rate (“private per diem rate”) of
effective as of
(date current “private per diem rate” commenced). Resident and/or Resident’s Representative
recognize that this private per diem rate may be increased from time to time by
the Facility’s Board of Governors.
This per diem rate includes the cost
of the basic nursing care, dietary services, room housekeeping and any
additional services outlined in Section 1.A. above. Any additional costs of
services are additional costs to be paid by the Resident and/or Resident’s
Representative from the Resident’s income or resources. The facility shall bill
the Resident and/or Resident’s Representative for these additional costs on a
monthly basis. Payment is expected upon receipt of invoice, or no later than
ten (10) days of the billing date. There is an additional surcharge for a
private room which must be paid monthly.
Resident and/or Resident’s
Representative agree to apply promptly for eligibility and benefits under the
Medicaid program as soon as the Resident appears to meet such program’s
eligibility requirements. The Resident and/or Resident’s Representative shall
inform the Facility’s Admissions Coordinator, in writing, at least six (6)
months prior to the time that the Resident’s total assets and income will be
less than the amounts specified by Medicaid for Medicaid eligibility and
immediately complete the required application for Medicaid and supply a copy to
the Facility. If Resident is covered by Medicare or other governmental funding
source, or has supplemental or third party insurance, Resident and/or
Resident’s Representative agree to file forms on a timely basis to ensure
coverage by the payer and to take all actions necessary to cause Medicare,
Medicaid or other government funding source or insurance program to pay for the
Resident’s care. The Facility will
assist the Resident and or Resident’s Representative with the filing of the
above mentioned forms provided the Resident and/or Resident’s Representative
has provided the Facility with all the necessary information for completion of
said forms on a timely basis.
The Resident and/or Resident’s Representative
acknowledge and understand that in addition to the financial review by Medicaid,
a “Pre-Admission Screening” (“PAS”) will be conducted by the Medicaid District
Office staff to assess the Resident’s need for nursing home placement.
The Resident and/or Resident’s Representative
agree that the failure of the Resident and/or Resident’s Representative to
cooperate in filing on a timely basis for Medicaid or other reimbursement, does
not relieve them of financial responsibility to pay the private per diem rate
for the Facility’s services. For example, if Resident would be eligible for
Medicaid in March and no filing is made until June, Resident and/or Resident’s Representative
agree that they are responsible for payment of the private per diem rate until
Medicaid makes a determination of eligibility and assigns a date for Resident’s
reimbursements to begin.
The Facility reserves the right to
change the daily base rate upon thirty (30) days prior notice. Any refunds due
the Resident for fees paid by the Resident and/or Resident’s Representative to
the Facility will be paid in accordance with the Facility’s policies and procedures.
2. Cost of Additional Services: The Resident and/or Resident’s Representative from the
Resident’s income and resources, agrees to pay for the cost of all additional
services and supplies which are not covered by Medicaid or Medicare or other governmental
funding source or by any other third party payer the Resident may have or which
are the responsibility of the facility under the government’s prospective
payment or consolidated billing requirements.
All third party caregivers and
companions are required to attend all mandatory in-service programs, register
with the Facility, and obey all Facility rules and policies and procedures
including, but not limited to wearing appropriate uniforms and I.D. badges,
signing Facility registers, etc.
All third party caregivers and
companions are subject to criminal background checks. If they fail such checks
or fail to comply with having these checks, the Resident and/or Resident’s
Representative will be notified that the Facility disapproves of the caregiver
or companion and that person will not be permitted to provide services at the
Facility.
3. Late Fees and Collection
Fees:
The Facility reserves the right to
charge one and one-third percent (1 1/3 %) interest per month (annual
percentage rate of sixteen (16%) on any past due balance. The “past due
balance” shall be any payment which is not received within sixty (60) days of
the billing or due date, whichever is earlier. In the event that any account
shall remain unpaid for ninety (90) days or more after billing or becoming due,
and should the services of a collection agency or an attorney be used to
collect the account, the Resident and/or Resident’s Representative agree to pay
the reasonable cost of collection and/or attorney’s fees and costs.
B.
FINANCIAL DISCLOSURE:
The Resident and/or Resident’s
Representative agree that the admission and continued stay of the Resident in
the Facility is contingent upon submission by the Resident and/or Resident’s Representative
and acceptance by the Facility, of an accurate disclosure of the Resident’s
assets and income at the time of application, upon admission.
In the event that Medicaid determines
that the Resident is ineligible for coverage because of actions taken by the
Resident and/or Resident’s Representative or otherwise, the Resident and/or Resident’s
Representative agree to pay the Facility’s private per diem rate and additional
services, if any, as otherwise outlined in this agreement.
When the
Resident becomes Medicaid eligible or if the Resident is admitted to the
Facility directly under the Medicaid Program, to the extent allowed by the
Medicaid regulations, all supplemental income, including but not limited to
Social Security, pension, etc. must be assigned to the Facility at the time of
admission to be applied toward the Resident’s account. A change of address form must be completed for all supplemental income
including but not limited to Social Security checks, pension, etc. at the time
the Resident is admitted. The Resident and/or Resident’s Representative is
responsible for submission of the Resident’s Social Security check at the
beginning of each month until the new address is in use by Social Security. The
Resident’s monthly account statement will reflect the Social Security payment of
the prior month.
III. RESIDENT’S AND/OR RESIDENT’S REPRESENTATIVE’S RESPONSIBILITIES:
It is understood by all parties to
this Agreement that the Resident and/or Representative shall be responsible for
the following:
A. Prompt payment of the costs
of the Resident’s care from the Resident’s income and resources.
B. The filing of financial
disclosures at the time of Admission and on a quarterly basis thereafter, and the
Resident’s Representative shall complete and execute the “Voluntary Request
for Responsible Representative” form.
C. The making of applications for
third party payments on a timely basis including but not limited to Medicaid,
Medicare, long term care insurance, etc.
D. The providing of personal
clothing and effects as needed or desired by Resident. All Resident’s clothing
must have labels with the Resident’s name. The Resident and/or Resident’s
Representative is responsible for bringing all clothing to the Social Service/Admissions Office for labeling.
E. The provision of spending
money as needed or desired by Resident.
F. Notification to Facility of
any leaves of absence such as vacation. Resident and/or Resident’s Representative
understand and acknowledge that Resident and/or Resident’s Representative remain
responsible for payment of the costs of Resident’s care from the Resident’s
income and resources during such leaves of absence.
G. Notification to the
Facility of any address and telephone number changes, including but not limited
to, the Resident’s Representative, guardian and Resident’s family.
H. Abiding by the Facility’s
rules, regulations, policies and procedures governing the relationship with
Resident and/or Resident’s Representative.
If the designated Resident’s Representative
is no longer willing or able to act, the Resident will designate a successor
Representative, or, if the Resident refuses to or is unable to appoint a
successor Representative for any reason, or no Representative is designated,
he/she hereby authorizes the Facility, at the expense of the Resident, to apply
to a Court of Competent Jurisdiction for the appointment of a Conservator or
Guardian of the Resident’s person and estate.
IV.
HEALTH CARE REPRESENTATIVE:
The Resident understands that he/she
has certain legal rights to appoint a health care representative to represent him/her
regarding his/her health care in the event he/she is unable to do so
personally. The Resident acknowledges that he/she has been provided with
written information by the Facility regarding Advanced Directives for
Healthcare or already has executed a Living Will and/or Advanced Medical
Directive which has been provided to the Facility. The Resident acknowledges
that he/she also has been provided with the Facility’s Organ Donation Policy
which is addressed in the Advanced Directives for Healthcare form provided by
the Facility.
V. RIGHTS OF RESIDENT:
The Rights of the Resident under this
Agreement are those stated herein, and those stated in the Residents Bill of
Rights, as listed in the “Things to Know About Daily Life at Daughters of
Israel” Handbook, which the Resident
acknowledges as having been received, and acknowledges that that Applicant has
read and understands these Rights. It is further understood that while the
Rights of Residents is intended to be consistent with all State and/or Federal
statutes and regulations, that any amendments or clarifications to those
statutes and/or regulations would supersede and be applicable to this
Agreement. The Resident’s rights do not include any proprietary interests
(ownership) in the property or assets of the Facility.
VI.
RIGHTS OF ENTRY AND DAMAGE AND REPAIRS:
The Resident understands that
employees of the Facility may have access and enter the Resident’s room on a
twenty-four (24) hour basis.
In case of destruction of and/or any
damage of any kind whatsoever to the Facility premises or property caused by
the carelessness, negligence or improper conduct on the part of the Resident, Resident’s
Representative, Resident’s guests, invitees, the Resident and/or Resident’s
Representative and/or Resident’s guests, invitees shall be responsible for
payment of any required repair, replacement and/or restoration of same from the
Residents income and/or resources.
VII. PAYMENT OF OUTSTANDING DEBTS, DISPOSITION OF PROPERTY OR REMOVAL OR
DEATH OF RESIDENT; FUNERAL EXPENSES:
Upon removal or death of Resident or
termination of this Agreement, the Resident’s outstanding debts due the
Facility shall be paid by the Resident’s Estate or his/her Representative from
the Resident’s income or resources within twenty (20) days of the date of the
Facility’s final bill. The Facility will use ordinary care in safeguarding the
Resident’s property and, if necessary, charge the Resident’s estate for such
storage. The removal of the Resident’s belongings from the Facility shall be
accomplished within thirty (30) days. Payment of any storage charges shall be
paid by the Resident’s estate or his/her Representative from the Resident’s
income or resources within ten (10) days of presentment of bill. The contents
will be released to the Resident’s Representative or responsible party
indicated on the Resident’s records at the time of admission to the Facility or
to the Executor/Executrix of the Resident’s estate if there is no
Representative or responsible party. If neither the Resident’s Representative
nor the Executor/Executrix claims the Resident’s belongings within the thirty
(30) days following termination, removal or death, the Facility may dispose of
the Resident’s belongings. This provision shall survive termination of this
agreement.
The Facility shall have no
responsibility for the burial of Resident upon Resident’s death. The Resident’s
Representative or next of kin shall arrange for removal of the body within
forty-eight (48) hours after notification of death; otherwise the Facility will
make arrangements for the removal of the deceased Resident at the expense of
the Resident’s estate.
VIII.
REPRESENTATION:
The Resident’s application forms,
financial statements, and health history
are a part of this Agreement. Any material omission or misrepresentation in
connection with any of these shall render this Agreement void at the option of
the Facility.
IX.
RULES, REGULATIONS,
POLICIES AND PROCEDURES:
The Resident and/or Resident’s Representative
agree to abide by the rules, regulations, policies and procedures and to
amendments, modifications or changes thereof, as established by the Facility,
and the Resident and/or Resident’s Representative agree to abide by this
Agreement. It is understood that the Resident’s guests, invitees, etc. also
shall abide by the same. The Facility reserves the right to amend or change
these rules, regulations, policies and procedures from time to time. The
Facility’s rules, regulations, policies and procedures shall not be construed
as imposing contractual obligations on the facility or granting any contractual
rights to Resident and/or Resident’s Representative.
X.
TERMINATION:
A. Death
of Resident:
This Agreement terminates upon the
death of the Resident. All obligations of the Facility under this Agreement
will cease at that time.
B. Termination
by Facility:
The Facility may terminate this
Agreement and discharge the Resident as provided in this Agreement or if
Resident has failed to provide notice of an extended absence from the Facility
and ceases to reside in the Facility for thirty (30) days.
C. Termination by Resident:
This Agreement may be terminated by
the Resident, provided he/she or the Resident’s Representative gives the
Facility prior written notice of his/her desire to terminate same, of at least
thirty (30) days unless such notice is not possible. The discharge of the
Resident or termination of the Agreement
shall in no way affect, modify or reduce any accrued charges or fees owed on
the Resident’s account prior to the effective date of the discharge or the
termination.
D. Short Stay and Long Term Residents:
This Agreement shall be completed by
both Short Stay Residents and Long Term Residents upon admission. The
Application/Agreement of a Resident shall remain in full force and effect so
long as the Resident resides in the Facility.
XI.
ADMISSION WAIVER:
The Facility has agreed to exercise
such responsible care toward the Resident as his or her known condition may
require; however, the Facility is not an insurer of the Resident’s safety or
welfare and assumes no liability as such.
The Facility will not be responsible
for the loss of or damage to any personal belongings, valuables or money left
in the possession of the Resident, in the Resident’s room or elsewhere in the
Facility.
The Facility will not be responsible
for debts incurred by the Resident while residing in the Facility.
XII.
GOVERNING LAW:
This Agreement shall be governed by
the laws of the State of
New Jersey.
XIII. CONFIDENTIALITY OF RECORDS:
XIV.
ASSIGNMENT:
Resident may not assign his/her
respective rights and obligations under this Agreement without the prior
written consent of the Facility which consent may be withheld, conditioned or
delayed. Facility shall have the right to assign this Agreement.
XV.
NOTICES:
A.
Any
notices required or permitted to be given under this Agreement shall be in
writing and shall be addressed to the parties as first set forth herein or to
such other address as may be specified in a prior written notice to the other
party.
B.
All
notices required or permitted under the terms of this Agreement shall be in
writing and shall be deemed delivered upon the earlier of (1) actual receipt by
addressee or (2) two (2) days following date of deposit in any branch of the
United States Postal Service.
C.
In
the event of a merger of the Facility with another entity, or the sale of all
of its stock or assets, reasonable notice shall be given to the Resident and/or
Resident’s Representative, if applicable.
XVI. DISPUTE RESOLUTION/ARBITRATION:
The Resident, and/or Resident’s
Representative and the Facility agree to attempt to resolve any disputes,
controversies, defaults or claims against the other in accordance with the Resident
grievance and dispute resolution procedures in effect at the facility.
In the event the parties cannot
resolve their dispute(s) pursuant to the Facility’s Grievance and Complaint
Procedure, the parties agree that all claims including, but not limited to,
those that arise out of or relate to this Agreement, shall be settled by
arbitration, which shall be initiated by either party hereto by providing
written notice of demand for arbitration to the other party. Such arbitration
shall take place in Essex County, New Jersey and be in accordance with either
the Commercial Arbitration Rules of the American Arbitration Association or the
American Health Lawyers Association Alternative Dispute Resolution Service
Rules of Procedure for Arbitration that in effect and by one (1) arbitrator
selected in accordance with the selected rules. The party requesting
arbitration shall select one of the aforesaid arbitration programs. The
determination of the arbitrator shall be conclusive and binding upon the
parties and judgment on the award rendered by the arbitrator(s) may be entered
in any court of competent jurisdiction.
Proceeding to arbitration and
obtaining an award there under shall be a condition precedent to the bringing
or maintaining of any action in any court with respect to any dispute, except
for the institution of a civil action for injunctive relief or to otherwise maintain
the status quo during the pendency of any arbitration proceeding. All expenses
and fees of the arbitrator and expenses for the hearing facilities and other
like expenses of the arbitration shall be borne equally by the parties unless
agreed otherwise or unless the award assesses such expenses against one of the
parties or allocates such expenses other than between the parties. All disputes
not resolved under this Section of the Agreement shall be submitted to the
Superior Court of New Jersey, Essex County, New
Jersey.
XVII.
OTHER PERSONS NOT A PARTY:
No person shall have any rights under
this Agreement unless the person is a party hereto or an officer, employee or
agent of a party hereto. This Agreement is not intended to create any rights in
any person, who is not a party hereto, or an officer, employee, or agent of a
party hereto. It is expressly not the intent of the parties hereto to make any
third party a third party beneficiary of this Agreement.
XVIII.
WAIVER:
The waiver by any party of a breach or
default of any provision of this Agreement shall not operate as a waiver of any
subsequent breach or default hereof.
XIX.
HEADINGS:
The headings placed before the various
sections and subsections of this Agreement are inserted for ease of reference
only, do not constitute a part of this Agreement and shall not be used in any
way whatsoever in the construction or interpretation of this Agreement.
XX.
ENTIRE AGREEMENT:
The parties hereby acknowledge that
this document contains the entire agreement between the parties. No
representations, promises, conditions or warranties with reference to this
Agreement have been entered into or relied upon except as expressly provided in
this Agreement and in the Addendum (Admission Forms Checklist, Things to Know
About Daily Life at Daughters of Israel Handbook, Advance Directives for
Healthcare) attached hereto.
XXI. AMENDMENT:
No amendment of this Agreement shall
be effective unless it is in writing and executed by duly authorized
representatives of the Facility and the Resident.
XXII.
SEVERABILITY:
Should any part or parts of this
Agreement be or become invalid or unenforceable, the remainder of this
Agreement shall remain in full force and effect.
All disputes not resolved under
Section XIV. herein under this Agreement shall be submitted to the Superior
Court of New Jersey,
Essex County,
New Jersey.
XXIII.
CERTIFICATION:
The Resident and/or the Resident’s
Representative, if applicable, by signing this Agreement certify that they have
read this entire Agreement as well as the Addendum (Admission Forms Checklist,
Things to Know About Daily Life at Daughters of Israel Handbook, Advance
Directives for Healthcare) attached hereto and understand and accept them in
full.
IN WITNESS WHEREOF, the Facility, Resident,
and/or Representative, if applicable, have executed this Agreement the day and
year first written below:
Daughters of
Israel:
Resident:
Resident’s Representative (if applicable):
STATE OF NEW JERSEY
COUNTY
OF ESSEX
I certify that on this
day of , 20, the following persons
personally
appeared before me and acknowledged under oath to my satisfaction that they are
the persons who are named in and who executed this instrument, and that they
signed, sealed and delivered this instrument as their voluntary acts and deeds
for the purposes expressed in the instrument.
Notary Public
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