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Rev 2/23/2001 <br /> 1`y Page 6 of 6 <br /> "4 <br /> Preparer reps esents that to the best of the Preparer's knowledge the above statements and facts are <br /> true and coi rect and to the best of the Preparer s actual knowledge no material facts have been <br /> suppressed or misstated <br /> k <br /> r <br /> User's Signature Date <br /> Preparer's Signature Dat <br /> F <br /> Respondant's Signature Date <br /> r ' <br /> � h <br /> { <br /> y� <br /> J ' <br /> r4� <br /> 2 <br /> s <br /> O Wonm\Field Forms\ESAUransaction Screen Quesuonaire doc <br /> t <br /> Initials <br />