RPVCCA_CC_SR_2012_03_20_E_State_Franchise_Tax_Board_Annual_Tax_Data_Exchange_With_CityCITY OF
MEMORANDUM
Rt\NCHO PALOS VERDES
TO:
FROM:
DATE:
SUBJECT:
REVIEWED:
Staff Coordinator:
HONORABLE MAYOR &CITY COUNCIL MEMBERS ~
DENNIS McLEAN,DIRECTOR OF FINANCE &INFORMATION
TECHNOLOGY
MARCH 20,2012
AGREEMENT BETWEEN CITY OF RANCHO PALOS VERDES
AND THE STATE OF CALIFORNIA FRANCHISE TAX BOARD TO
EXCHANGE ANNUAL TAX DATA
CAROLYN LEHR,CITY MANAGER~
Matt Waters,Senior Administrative Analyst
RECOMMENDATION
Adopt Resolution No.2012-,authorizing the City of Rancho Palos Verdes (City)to enter into
a reciprocal agreement with the State of California Franchise Tax Board (FTB)to allow for
the exchange of tax data to;a)assist the FTB in identifying individuals who are not filing
required individual and business entity income tax returns with the State;and,b)potentially
assist the City in identifying businesses that have not paid business license taxes.
BACKGROUND AND DISCUSSION:
California Government Code 19551.5 states that any city that assesses a business tax or
requires a business license needs to submit the collected tax administration to the Franchise
Tax Board at its request.This information includes business name,address,Federal
Employee Identification Number (FEIN)or Social Security Number (SSN),ownership type
and business start and end dates.Since January 2009,the FTB and participating California
Cities have exchanged tax-related data through the FTB's City Business Tax Program.Data
provided by participating cities helps the FTB identify self-employed individuals who have not
filed required individual and business entity tax returns.Data provided by the FTB can
potentially aid cities in identifying businesses that need to complete local business tax filing
requirements (such as the City's business license tax filing and payment).The intent of the
agreement is for both the State and participating cities to benefit by bringing in revenue that
might not be collected without the mutual exchange and analysis of data.
The Rancho Palos Verdes business license ordinance is non-regulatory and has been
enacted solely to raise revenue for municipal purposes.The FTB provides the data to the
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AGREEMENT BETWEEN CITY AND FRANCHISE TAX BOARD
March 20,2012
Page 2
City at no cost.While it may have the potential to generate additional revenue,based on
previous experience analyzing FTB data submissions,Staff is cautious about the practical
usability of the information.Staff intends to review and assess the information received by
the FTB on an annual basis to ascertain the merits of pursuing possible non-filings of the
City's business license applications and tax payments.
Participating cities provide the FTB with the following information:
~Business and owner's name
~Business or residence address
~FEIN orSSN
~North American Industry Classification Code or Standard Industry
Classification Code
The FTB provides cities with the following information:
~Taxpayer name
~Taxpayer address
~Taxpayer FEIN or SSN
~Entity Type
~Principal Business Activity (PBA)Code from Form 540-California Resident
Income Tax Return
Due to its confidential nature,all data being sent to the FTB or received from the FTB is
transmitted using an FTB-maintained Secure Web Internet File Transfer (SWIFT)account.
Participating cities are required to complete a City Business Tax Safeguard Review
Questionnaire.Only city employees who have signed a required confidentiality statement
will have access to the data.The data will only be used for the administration of tax within
the City and the destruction of the data is mandated after three years.
Over one-hundred California Cities,including the cities of Los Angeles,Long Beach,
Newport Beach,and Rancho Palos Verdes participate in the City Business Tax program as
of June,2011.The proposed agreement between the FTB and the City has a term lasting
from June 1,2012 through December 31,2014.The City agrees to provide the FTB with
data annually in June for 2012,2013,and 2014.The FTB will provide the City with tax
information in December 2012 for tax year 2011,December 2013 for tax year 2012,and
December 2014 for tax year 2013.
FISCAL IMPACT
Neither the City nor the FTB pays any fee to enter into this agreement.The City is legally
obligated to provide tax data to the FTB.It is unknown how much additional business
license tax revenue would be generated as a result of this agreement.
ATTACHMENTS:
Resolution No.2012-
State of California Agreement between Franchise Tax Board and City (C11 00230)
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RESOLUTION NO.2012-
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF RANCHO PALOS
VERDES,AUTHORIZING THE CITY OF RANCHO PALSO VERDES TO
ENTER INTO AN AGREEMENT WITH THE STATE OF CALIFORNIA
FRANCISE TAX BOARD AUTHORIZING THE RECIPROCAL AND
CONFIDENTIAL EXCHANGE OF TAX DATA
WHEREAS,businesses operating in the City of Rancho Palos Verdes are required to
pay all legally mandated local business forms and taxes;and,
WHEREAS,the City of Rancho Palos Verdes is required to report required tax
information to the State of California Franchise Tax Board annually;and,
WHEREAS,self-employed individuals in the State of California are required to file
appropriate individual and business entity income tax returns;and,
WHEREAS,entering into a reciprocal agreement with the State of California's Franchise
Tax Board's City Business Tax program will provide reciprocal tax information that may identify
businesses in the City of Rancho Palos Verdes that have local business tax obligations;and,
WHEREAS,the term of the agreement between the City of Rancho Palos Verdes and
the State of California's Franchise Tax Board's City Business Tax Program will be from June 1,
2012 to December 31,2014;and
NOW THEREFORE,THE CITY COUNCIL OF THE CITY OF RANCHO PALOS
VERDES DOES HEREBY FIND,DETERMINE AND RESOLVE AS FOLLOWS:
Section 1:The City of Rancho Palos Verdes enters into a reciprocal agreement with the
State of California's Franchise Tax Board,is approved and adopted by the City Council.
Section2.This resolution shall take effect immediately.
PASSED,APPROVED,AND ADOPTED THIS 20th DAY OF MARCH 2012.
Mayor
ATTEST:
City Clerk
State of California )
County of Los Angeles )ss
City of Rancho Palos Verdes )
I,Carla Morreale,City Clerk of the City of Rancho Palos Verdes,hereby certify that the above
Resolution No.2012-was duly and regularly passed and adopted by the said City Council at a
regular meeting thereof held on March 20,2012.
City Clerk
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STATE OF CALIFORNIA
STANDARD AGREEMENT
STD 213 (Rev 06/03)
AGREEMENT NUMBER
C1100230
REGISTRATION NUMBER
1.This Agreement is entered into between the State Agency and the Contractor named below:
STATE AGENCY'S NAME
Franchise Tax Board
CONTRACTOR'S NAME
City of Rancho Palos Verdes
2.The term of this
Agreement is:June 1,2012 through December 31,2014
3.The maximum amount $0.00
of this Agreement is:NON-FINANCIAL AGREEMENT
4.The parties agree to comply with the terms and conditions of the following exhibits,which are by this reference made
a part of the Ag'reement.
Exhibit A -Scope of Work
Exhibit C*-General Terms and Conditions
Exhibit 0 -Special Terms and Conditions
Exhibit E -City Record Layout Specifications
Exhibit F -FTB Record Layout Specifications
Exhibit G -Confidentiality Statement
3 pages
GTC610
3 pages
2 pages
1 page
1 page
Items shown with an Asterisk (*),are hereby incorporated by reference and made part of this agreement as if attached hereto.
These documents can be viewed at www.ols.dgs.ca.gov/Standard+Language/default.htm
IN WITNESS WHEREOF,this Agreement has been executed by the parties hereto.
CONTRACTOR California Department of General
Services Use Only
CONTRACTOR'S NAME (if other than an individual,state whether a corporation,partnership,etc.)
City of Rancho Palos Verdes
BY (Authorized Signature)DATE SIGNED(Do not type),
J6
PRINTED NAME AND TITLE OF PERSON SIGNING
ADDRESS
30940 Hawthorne Blvd.,Rancho Palos Verdes,CA 90275
STATE OF CALIFORNIA
AGENCY NAME
Franchise Tax Board
BY (Authorized Signature)DATE SIGNED(Do not type)
iiK
PRINTED NAME AND TITLE OF PERSON SIGNING IZI Exempt per:SCM 4.04.5.b.
Lisa Garrison,Chief Financial Officer
ADDRESS
P.O.Box 2086,Rancho Cordova,CA 95741-2086
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City of Rancho Palos Verdes
SCOPE OF WORK
EXHIBIT A
Agreement #C1100230
This Agreement is entered into by and between the Franchise Tax Board,herein referred to as
(FTB)and the City of Rancho Palos Verdes,herein after referred to as the City.
Purpose:
This Agreement allows FTB and the City to enter into a reciprocal agreement to exchange tax
data specific to city business license information for tax administration and non-tax program
purposes.By entering into a reciprocal agreement,each party agrees to bear its own costs of
providing the data and the City is precluded from obtaining reimbursement.
Both parties will abide by the legal and confidentiality provisions of this Agreement.Exhibits A,
C,D,E,F,'and G attached hereto and incorporated by reference herein,set forth additional
terms to which the parties agree to be bound.
This Agreement does not include Federal Tax Information (FTI).
Legal Authority:
California Revenue and Taxation Code (R&TC)Section 19551.1 authorizes a reciprocal
agreement for the exchange of city business tax and income tax information between a city and
FTB.R&TC Section 19551.5 mandates cities to provide city business tax data to FTB upon
request.
City Responsibilities:
1.The City agrees that the information provided by FTB will be used exclusively to administer
the City's business tax program.
2.The City agrees to provide FTB with tax information pursuant to City Record Layout
Specifications,Exhibit E.
3.The City agrees to extract and provide City data to FTB annually in June for each tax year
that the Agreement is in place;June 2012,2013,and 2014.If the Agreement is executed
after June 30,2012,the City has 30 days after execution to provide FTB with the first year's
data.
4.The City agrees to submit the records to FTB using FTB's Secure Web Internet File Transfer
(SWIFT).
5.The City agrees to submit the records to FTB in ASCII fixed length format,.txt,per the City
Record Layout Specifications,Exhibit E.
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City of Rancho Palos Verdes
SCOPE OF WORK (continued)
EXHIBIT A
Agreement #C1100230
6.The City agrees to resubmit data in the event data is initially submitted with errors.The
resubmission of data must be within 30 days of notification.If data is not submitted
accurately and timely,the City forfeits its rights to FTB data for that year.
7.The City agrees that each City employee having access to FTB data shall sign a
Confidentiality Statement,Exhibit G.The signed statement is to be retained by the City and
produced to FTB upon request.
8.The City agrees to submit to FTB a completed Safeguard Review Questionnaire prior to
receiving FTB data.The Safeguard Review Questionnaire is valid for the duration of the
Agreerrent.
9.The City agrees to provide a copy of the resolution,order,motion,or ordinance of the local
governing body,authorizing the execution of the Agreement.
FTB Responsibilities:
1.FTB agrees that information provided by the City will be used for tax administration and non-
tax programs that FTB administers and may be shared with other state/federal agencies as
authorized by law.
2.FTB agrees to provide the City data extracted from the Taxpayer Information (TI)and
Business Entities Tax System (BETS).FTB will provide the City records for taxpayers within
the city's jurisdiction who indicate business income or deductions on their personal or
corporation income tax return pursuant to FTB Record Layout Specifications,Exhibit F.
3.FTB agrees to match the data provided by the City using the social security number or
federal employer identification number against FTB's data with a yes or no indicator on the
FTB Record Layout Specifications,Exhibit F.The first year's data match is at the discretion
of FTB and will be based on when the data is received and processed.
\
4.FTB agrees to provide the City an annual extract file in December 2012 for tax year 2011,
December 2013 for tax year 2012,and December 2014 for tax year 2013 via SWIFT.
5.FTB agrees to register the City for a SWIFT account,allowing for the secure electronic
transmission of data.
6.FTB agrees to provide the City a unique City Business Tax Number to be used for reporting
purposes only.
7.FTB agrees to allow the City to resubmit data within 30 days of notification,in the event data
is initially submitted with errors.
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City of Rancho Palos Verdes
EXHIBIT A
SCOPE OF WORK (continued)
Project Coordinators:
The project coordinators during the term of this Agreement will be:
Agreement #C11 00230
Franchise Tax Board
Cathy McCollum
Data Resources and Services Unit
P.O.Box 1468,Mailstop A181
Sacramento,CA 95812-1468
Phone:(916)845-4431
Fax:(~16)843-5899
Return executed Agreement to:
Franchise Tax Board
Procurement &Asset Management Bureau
Attention:Ta Nita Martinez
P.O.Box 2086,Mailstop A-374
Rancho Cordova,CA 95741-2086
Phone:(916)845-7199
Fax:(916)845-3599
City of Rancho Palos Verdes
Kathryn Downs
Deputy Director of Finance
30940 Hawthorne Blvd.
Rancho Palos Verdes,CA 90275
Phone:(310)544-5216
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City of Rancho Palos Verdes
SPECIAL TERMS AND CONDITIONS
EXHIBIT D
Agreement #C11 00230
1.STATEMENT OF CONFIDENTIALITY:The Franchise Tax Board has tax return
information and other confidential data in its custody.Unauthorized inspection or disclosure
of state return information or other confidential data is a misdemeanor (Sections 19542 and
19542.1 Revenue and Taxation Code).
The City and each of the City's employees who may have access to the confidential data of
FTB will be required to sign a Confidentiality Statement,Exhibit G,attesting to the fact that
he/she is aware of the confidential data and the penalties for unauthorized disclosure
thereof.The signed statement shall be retained by the City and furnished to FTB upon
request.
2.USE OF INFORMATIO~:The City and FTBagree that the information furnished or secured
pursuant to this Agreement shall be used solely for the purposes described in the Scope of
Work,Exhibit A.The information obtained by FTB shall be used for tax administration and
nontax programs that FTB administers and may be shared with other state/federal
agencies as authorized by law.The City and FTB further agree that information obtained
under this Agreement will not be reproduced,published,sold,or released in original or in
any other form for any purpose other than identified in this Agreement or as authorized by
law.
3.DATA OWNERSHIP:The confidential tax information or sensitive information being
provided to the City under this Agreement remains the exclusive property of FTB.
Confidential tax and sensitive data/information are not open to the public and require
special precautions to protect from loss and unauthorized use,disclosure modification,or
destruction.The City shall have the right to use and process the disclosed information for
the purposes stated in the Scope of Work,Exhibit A,of this Agreement,which right shall be
revoked and terminated immediately upon completion of this Agreement.
4.EMPLOYEE ACCESS TO INFORMATION:Both FTB and the City agree that the
information obtained will be kept in the strictest confidence and shall make information
available to its own employees only on a "need to know"basis.The "need to know"
standard is met by authorized employees who need information to perform their official
duties in connection with the uses of the information authorized by this Agreement.Both
parties recognize their responsibilities to protect the confidentiality of this information as
provided by law and ensures such information is disclosed only to those individuals and of
such purpose,as authorized by the respective laws.
5.PROTECTING CONFIDENTIAL INFORMATION:Both FTB and the City in recognizing the
confidentiality of the information being exchanged,agree to take all appropriate precautions
to protect the confidential information obtained pursuant to this Agreement from
unauthorized disclosure.Both FTB and the City will conduct oversight of its users with
access to the confidential information provided under this Agreement.
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City of Rancho Palos Verdes
EXHIBIT D
SPECIAL TERMS AND CONDITIONS (continued)
Agreement #C11 00230
6.INFORMATION SECURITY:Information security is defined as the preservation of the
confidentiality,integrity,availability,authenticity,and utility of information.A secure
environment is required to protect the confidential information obtained from FTB pursuant
to this Agreement.The City will store information so that it is physically secure from
unauthorized access.The records received by the City will be securely maintained and
accessible only by employees of the city business license program who are committed to
protect the data from unauthorized access,use,and disclosure.
7.INCIDENT REPORTING:All unauthorized or suspected unauthorized access;use and/or
disclosure (incidents)of FTB data shall be reported to FTB's City Business Tax Program
Area,(916)845-6304 or by email:LocaIGovtLiaison@ftb.ca.gov ,immediately upon
discovery of the incident.The incident report shall contain the following:date,time,
employee name,description of the incident or circumstances,and means of discovery.
Upon discovery of any such incident,FTB will make the appropriate notification to affected
California resident(s)pursuant to the requirements of Civil Code Section 1798.29.
8.DESTRUCTION OF RECORDS:All records received by the City from FTB and any
database(s)created,copies made,or files attributed to the records received will be
destroyed within three years of receipt.The records shall be destructed in a manner to be
deemed unusable or unreadable and to the extent that an individual record can no longer
be reasonably ascertained.FTB will destroy City data in accordance with the Department's
data retention policies.
9.SAFEGUARD REVIEW QUESTIONNAIRE AND ON-SITE SAFEGUARD REVIEW:Prior to
sending data to the City,FTB requires the City to submit a Safeguard Review
Questionnaire certifying the protection and confidentiality of FTB data.The FTB retains the
right to conduct an on-site safeguard review of the City.The City will be provided a
minimum of seven (7)days'notice prior to an on-site safeguard review being conducted by
the FTB Disclosure Office.The on-site safeguard review will examine the adequacy of
information security controls established by the City in compliance with the confidentiality
requirements pursuant to this Agreement.The City will take appropriate disciplinary actions
against any user determined to have violated security or confidentiality requirements.
10.DISPUTE RESOLUTION:In the event of a dispute,the City shall file a "Notice of Dispute"
with the Chief Financial Officer of the Franchise Tax Board within ten (10)days of discovery
of the problem.Within ten (10)days,the Chief Financial Officer or his/her designee shall
meet with the City and the FTB contact for purposes of resolving the dispute.The decision
of the Chief Financial Officer shall be final.
11.INDEMNIFICATION:Both parties agree to indemnify,defend,and save harmless each
other,its officers,agents,and employees from any and all claims and losses accruing or
resulting from any breach of confidentiality by either party and/or its employees.
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City of Rancho Palos Verdes
EXHIBIT D
SPECIAL TERMS AND CONDITIONS (continued)
Agreement #C11 00230
12.LIMITED WARRANTY:Either party does not warrant or represent the accuracy or content
of the material available through this Agreement,and expressly disclaims any express or
implied warranty,including any implied warranty of fitness for a specific purpose.
13.CANCELLATION:Either party may terminate this Agreement,in writing for any reason,
upon thirty days'(30)prior written notice.This Agreement may be terminated by either
party in the event of any breach of the terms of this Agreement.Both parties agree that in
the event of a breach to the terms of this Agreement,it shall destroy all records and any
databases created,copies made,or files attributed to the records received.The records
shall be destructed in a manner to be deemed unusable or unreadable and to the extent
that an individual record can no longer be reasonably ascertained,upon destruction.
14.NO THIRD PARTY LIABILITY:Nothing contained in this Agreement or otherwise shall
create any contractual relation between either party and any other party,and no party shall
relieve the City or FTB of its responsibilities and obligations hereunder.Both parties agree
to be fully responsible for the acts and omissions of its third parties and of persons either
directly or indirectly employed by any of them as it is for the acts and omissions of persons
directly employed by the City or FTB.Both parties shall have no obligation to payor to see
the payment of any monies to any party or persons either directly or indirectly employed by
the City or FTB.
15.EARLY TERMINATION CLAUSE:In the event that Revenue &Taxation Code 19551.1 and
19551.5 are not amended before the sunset date of December 31,2013,this Agreement
will be terminated effective that date.
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City of Rancho Palos Verdes Agreement #C1100230
EXHIBIT E
CITY RECORD LAYOUT SPECIFICATIONS
Data Element Name Start End Field Usage Description
Pos. Pos.Size
SOCIAL SECURITY NUMBER 1 9 9 AN Must be present unless FEIN is
(SSN)provided.Fill unused field with
blanks.
FEDERAL EMPLOYER 10 18 9 AN Must be present unless SSN is
10 NUMBER (FEIN)provided.Fill unused field with
blanks.
OWNERSHIP TYPE 19 19 1 AN Must be present:
S =Sole Proprietorship
P =Partnership
C =Corporation
T =Trust
L =Limited Liability Company
OWNER'S LAST NAME 20 34 15 AN Must be present if Ownership Type
in position 19 =S.
OWNER'S FIRST NAME 35 45 11 AN Must be present if Ownership Type
in position 19 =S.
OWNER'S MIDDLE INITIAL 46 46 1 AN May be left blank.
BUSINESS NAME 47 86 40 AN Enter if business is operating under
a fictitious name (Doing Business
As (DBA».
BUSINESS ADDRESS 87 126 40 AN Address of the business location or
NUMBER AND STREET the residence of the owner if sole
proprietorship.
CITY 127 166 40 A Must be present.
STATE 167 168 2 A Enter standard state abbreviation.
ZIP CODE 169 177 9 AN Enter the five-or nine-digit ZIP
Code assigned by the U.S.Postal
Service.If only the first five-digits
are known,left-justify information
and fill the unused fields with
blanks.
BUSINESS START DATE 178 185 8 N Enter the eight-digit date
(MMDDYVYV).Zero fill if not
known.
BUSINESS CEASE DATE 186 193 8 N Enter the eight-digit date
(MMDDYYYY)if out of
business.Zero fill if not known or
still in business.
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City of Rancho Palos Verdes Agreement #C1100230
Data Element Name Start End Field Usage Description
Pas.Pas.Size
CITY BUSINESS TAX 194 196 3 N Enter three-digit number assigned
NUMBER by FTB.
NORTH AMERICAN 197 202 6 N Enter the six-digit NAICS code.Fill
INDUSTRY CLASSIFICATION unused fields with zeros.
SYSTEM (NAICS)
STANDARD INDUSTRIAL 203 206 4 N Enter the 2-4 digit SIC code.Left
CLASSIFICATION (SIC)justify (example 99 will be 9900).
Fill unused fields with zeros.
TOTAL RECORD LENGTH 206
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City of Rancho Palos Verdes
EXHIBIT F
Agreement #C1100230
FRANCHISE TAX BOARD RECORD LAYOUT SPECIFICATIONS
Field Name Length Start Description
Pos.
ENTITY TYPE 1 1 "P"-personal income tax record;
"B"-business entity tax record.
SSN or FEIN 9 2 For "P"records,primary taxpayer's social
security number;For "B"records,federal
employer identification number.
LAST NAME 40 11 For "P"records,the primary taxpayer's last
name;For "B"records,business name.
FIRST NAM.E 11 51 For "P"records ONLY.
MIDDLE INITIAL 1 62 For "P"records ONLY.
SPOUSE SSN 9 63 For "P"records filed with a joint return.
SPOUSE LAST NAME 17 72 For "P"records filed with a joint return.
SPOUSE FIRST NAME 11 89 For "P"records filed with a joint return.
SPOUSE MIDDLE INITIAL 1 100 For "P"records filed with a joint return.
PBACODE 6 101 Principal business activity code.
ADDRESS NUMBER 10 107
PRE-DIRECTIONAL DIRECTOR 2 117 Postal Service term (Le.,N,S,E,W,NE,
NW,SE,SW).
STREET NAME 28 119
STREET SUFFIX 4 147 e.g.,ST,WAY,HWY,BLVD,etc.
POST-DIRECTIONAL INDICATOR 2 151 Postal Service term (Le.,N,S,E,W,NE,
NW,SE,SW).
STREET SUFFIX 2 4 153
APARTMENT/SUITE NUMBER 10 157 e.g.,APT,UNIT,FL,etc.
CITY 13 167
STATE 2 180 Standard state abbreviation.
ZIP CODE 5 182 The five-digit ZIP Code assigned by the U.S.
Postal Service.
ZIP CODE SUFFIX 4 187 Provided if known.
CBT MATCH 1 191 "N"-No match per CBT data."Y"-Yes:
CBT matched to state tax return filed.
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City of Rancho Palos Verdes
State of California
EXHIBITG
CONFIDENTIALITY STATEMENT
Agreement #C1100230
Franchise Tax Board
Confidential tax return information is protected from disclosure by law,regulation,and
policy.Information security is strictly enforced.Violators may be subject to disciplinary,
civil,and/or criminal action.Protecting confidential tax return information is in the
public's interest,the state's interest,and the city's interest.
A city employee is required to protect all information received from the Franchise Tax
Board..
A city employee is required to protect confidential information by:
•Accessing or modifying information only for the purpose of performing official duties.
•Never accessing or inspecting information for curiosity or personal reasons.
•Never showing or discussing confidential information to or with anyone who does not
have the need to know.
•Placing confidential information only in approved locations.
•Never removing confidential information from your work site without authorization.
Unauthorized inspection,access,use,or disclosure of confidential tax return information
is a crime under state laws,including but not limited to Sections 19542 and 19552 ofthe
California Revenue and Taxation Code and Section 502 of the Penal Code.Unauthorized
access,inspection,use,or disclosure may result in either or both of the following:
•State criminal action
•State and/or taxpayer civil action
You are reminded that these rules are designed to protect everyone's right to privacy,including
your own.
/certify that I have read the confidentiality statement printed above.I further certify and
understand that unauthorized access,inspection,use,or disclosure of confidential
information may be punishable as a crime and may result in disciplinary and/or civil
action being taken against me.
Name
Signature Date
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