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Get Humana GCA09H4HH 2012-2021

Consent for Release Your guide to enrollment CoverageFirst PPO of Protected Health Information Medicare Commercial Member information person whose information will be released Your name Date of birth First Middle Last Month Day Year Address ZIP Street City State Member ID Group if applicable Phone Home Cell I understand that this authorization will allow Humana and its affiliates to use or disclose the protected health information described below Please check only ONE box Any and all protected health information Humana and its affiliates maintain including mental health HIV health status or substance abuse records. This also includes information on health programs plan information and caregiver resources with the person being authorized. This information can be disclosed to and used by the following people or organization Name Date of birth City State ZIP code Phone Relationship Spouse Sibling Parent Child Agent/Broker Friend Organization claim under my policy. Disapproval of this item on ROPS I and ROPS II and the subsequent unclear communication from DOF appearing to approve the item from LMIHF on ROPS I was one of several subjects of the Successor Agency s True Up Payment litigation against the County Auditor Controller and DOF and was addressed in discussions with DOF legal counsel leading up to the stipulated judgment issued by Sacramento County Superior Court on December 21 2012. Although this item was not directly addressed in the stipulated judgment the Successor Agency relied upon discussions with DOF legal counsel in determining its use of ROPS I and ROPS III RPTTF and in its request to amend its Housing Due Diligence Review. The 60 000 balance of the pre DDA obligation is being listed on ROPS 13 14A for funding with RPTTF consistent with the stipulated judgment discussions and DOF s initial ROPS III approvals. The outstanding obligation has been revised from prior ROPS based on estimated funding requirements under the terms of the agreement. Due to the uneven nature of the Successor Agency s FY2013 14 obligations of RPTTF the entire administrative allowance is being included on ROPS 13 14A. CITY COUNCIL RESOLUTION 2012-XX AGENCY SUCCESSOR AGENCY down the former redevelopment agencies affairs and of the City but the City is providing administrative services for the Successor Agency and WHEREAS the Dissolution Act requires the Successor Agency to prepare a Recognized obligations including an administrative cost allowance of 250 000 per fiscal year and WHEREAS Health Safety Code Section 34173 h allows the City to loan funds to the reported on a ROPS and approved by the Oversight Board and period January through June 2013 and the Department of Finance DOF approved the DOF over the True Up Payment the cost of which is an enforceable obligation of RPTTF that was included on the ROPS for July through December 2013 ROPS 13-14A so that the WHEREAS there are insufficient funds available in the RPTTF to pay all approved period and the litigation costs on ROPS 13-14A and WHEREAS the estimated cash flow advance to the Successor Agency required during the ROPS III period will be 238 000 and WHEREAS to enable the Successor Agency to meet its fiduciary responsibilities to holders of enforceable obligations and for the Successor Agency to have adequate funds for amount not to exceed 238 000 and WHEREAS Exhibit A to this Resolution is a proposed Cash Flow Loan Agreement Loan Agreement pursuant to the authority granted by Health and Safety Code Section 34173 h and WHEREAS the City and Successor Agency have determined that entering into the proposed Loan Agreement is in the best interests of the City and the Successor Agency and WHEREAS the Loan Agreement is subject to the approval of the Oversight Board of the hereby finds the above recitals to be true and accurate. Due to the uneven nature of the Successor Agency s FY2013 14 obligations of RPTTF the entire administrative allowance is being included on ROPS 13 14A. CITY COUNCIL RESOLUTION 2012-XX AGENCY SUCCESSOR AGENCY down the former redevelopment agencies affairs and of the City but the City is providing administrative services for the Successor Agency and WHEREAS the Dissolution Act requires the Successor Agency to prepare a Recognized obligations including an administrative cost allowance of 250 000 per fiscal year and WHEREAS Health Safety Code Section 34173 h allows the City to loan funds to the reported on a ROPS and approved by the Oversight Board and period January through June 2013 and the Department of Finance DOF approved the DOF over the True Up Payment the cost of which is an enforceable obligation of RPTTF that was included on the ROPS for July through December 2013 ROPS 13-14A so that the WHEREAS there are insufficient funds available in the RPTTF to pay all approved period and the litigation costs on ROPS 13-14A and WHEREAS the estimated cash flow advance to the Successor Agency required during the ROPS III period will be 238 000 and WHEREAS to enable the Successor Agency to meet its fiduciary responsibilities to holders of enforceable obligations and for the Successor Agency to have adequate funds for amount not to exceed 238 000 and WHEREAS Exhibit A to this Resolution is a proposed Cash Flow Loan Agreement Loan Agreement pursuant to the authority granted by Health and Safety Code Section 34173 h and WHEREAS the City and Successor Agency have determined that entering into the proposed Loan Agreement is in the best interests of the City and the Successor Agency and WHEREAS the Loan Agreement is subject to the approval of the Oversight Board of the hereby finds the above recitals to be true and accurate. execution of the Cash Flow Loan Agreement substantially in the form attached hereto as Exhibit A subject only to those changes approved by the City Manager and further subject to approval of City s advance of the Loan shall not exceed 238 000 and the Successor Agency shall list the loan as an enforceable obligation on future ROPS until the loan is paid in full at an interest rate on the Loan equal to the rate applicable to funds on deposit in the Local Agency Investment Fund. Refer to the Service Manual for the disassembly and assembly procedures that are necessary in order to perform the required maintenance on the items that are listed. Consult your Caterpillar dealer for assistance. needed to inspect the engine refer to Guidelines for Reusable Parts and Salvage Operations SEBF8029 Index of Publications on Reusability or Salvage of Used Parts. However while the funds reported were deposited into the LMIHF on December 16 2011 when they were considered tax increment they were transferred to the Successor Agency as RPTTF upon dissolution on January 31 2012 as directed by DOF. The Housing DDR was completed prior to the issuance of the stipulated judgment in the True Up Payment litigation which made clear that the funds were not LMIHF and should not have been reported on the Housing DDR. Rather the funds were RPTTF and were used to pay approved ROPS I items. Note that based on the unclear funding source of the Housing loan obligations approved on ROPS I the Successor Agency reported on its Housing DDR a LowModerate Income Housing Fund LMIHF balance as being held to pay those enforceable obligations on ROPS III. However while the funds reported were deposited into the LMIHF on December 16 2011 when they were considered tax increment they were transferred to the Successor Agency as RPTTF upon dissolution on January 31 2012 as directed by DOF. The Housing DDR was completed prior to the issuance of the stipulated judgment in the True Up Payment litigation which made clear that the funds were not LMIHF and should not have been reported on the Housing DDR. If you need assistance completing the application or have any other questions about the application process don t hesitate to contact Jeannie Bennett at LPEA 970 382-3505 or via email DONATION APPLICATION ORGANIZATION OR CHARITY P. O. BOX 2750 Durango Colorado 81302 Please complete all information. .

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