Form CMS-10333 Appendix 1

Appendix 1

OMB Control Number: 0938-1097
Expiration Date: XX/2019

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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 0938-1097. The time required to
complete this information collection is estimated to average 13,3111per 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.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated,
distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to
the full extent of the law.

6/26/2012