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Direct pay authorization Form: What You Should Know

I also certify, under penalty of perjury, that I am not the victim or a party to this complaint, either under any current or former order of an agency of the United States or under any Act of Congress, or in any way connected with the case, and that such agency of the United States or such act of Congress is a party to the proceeding in this case. I further state that I am not liable to the plaintiff, her heirs, executors, administrators, or assigns in any manner, for any losses or damages suffered by this action. Furthermore, I understand by signing this application that upon execution of this signature I am required by law to provide the information and documentation reasonably needed by the plaintiff to prosecute this action. Signed :                                                                                                                By _____________________________ VSP — PO BOX 997100 Sacramento, CA 95. VSP–Settlement Administrator–No. 1 — Date/No.   ____________________________________ VSP — Settlement Administrator — No. 2 — Date/No.   ____________________________________ VSP–Settlement Administrator — No. 3 — Date/No.   ____________________________________ VSP–Settlement Administrator -- No. 6 -- Date/No.   ____________________________________ VSP–Settlement Administrator -- No. 7 -- Date/No.   ____________________________________       _____________________________________ VSP — Settlement Administrator -- No. 8 -- Date/No.   ____________________________________ VSP — Settlement Administrator -- No. 9 -- Date/No.   ____________________________________ VSP — Office of Administration–No. 1-01 -- Date/No.  ____________________________________       _____________________________________       ____________________________________ VSP — Office of Administration — No. 2 — Date/No.  ____________________________________       ____________________________________       ____________________________________ VSP — Office of Administration — No. 3 — Date/No.  ____________________________________       ____________________________________       ____________________________________ VSP — Office of Administration — No. 4 — Date/No.  ____________________________________ VSP — Office of Administration — No.

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