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Rev 2/23/2001 <br /> Page 6 of 6 <br /> Preparer represents that to the best of the Pieparer's knowledge the above statements and facts are <br /> true and correct and to the best of the Preparer's actual knowledge no material facts have been <br /> suppressed or misstated <br /> s User's Signature Date <br /> Preparer's Stgnattrre to <br /> Respondant's Signature Date <br /> n <br /> r <br /> h <br /> t, <br /> Xw <br /> r <br /> 1 <br /> r � <br /> 0 Fonykff ie€d Forms\ESAMinsactim Screen Questionaire doc <br /> Initials <br />