Medicare Prescription Drug Benefit Program (PLAN)-(CMS-10141)

Attachment 1a - To be completed by all Organizations

2009 Compensation Certification

Organization Name:________________________________________

Certification Date:_______________________________________

CMS Contract Number(s):___________________________________

I have examined the compensation structure(s) described herein and attest that this accurately and completely represents the compensation structure(s) as of the certification date indicated on this document. The structure(s) herein meet the requirements set in CMS 4138-IFC2.

__________________________________ ___________

CEO (or other authorized official) Date

Attachment 1b – To be completed by Organizations using Option One to determine 2009 renewal commissions

2009 Compensation Certification

Organization Name:________________________________________

Certification Date:_______________________________________

CMS Contract Number(s):___________________________________

I have examined the compensation structure(s) for 2006 described herein and attest that this accurately and completely represents the initial compensation structure(s) in place at that time, and that the renewal compensation rate submitted for 2009 is 50% of the 2006 initial rate adjusted for inflation factors provided in CMS guidance on 2009 compensation structures. The structure(s) herein meet the requirements set in CMS 4138-IFC2.

__________________________________ ___________

CEO (or other authorized official) Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is

0938-0964. The time required to complete this information collection is estimated to average 49 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.