Form Trip 02b - Schedule B - Terrorism Risk Insurance Program Page 2

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Control Number________________
(Treasury Use)
Any false or fraudulent statements or claims may subject the insurer and signatory to criminal, civil, or
administrative penalties.
______________________________
__________________________________
__________________
Name
Officer Title
Date
______________________________
Signature
Notice Under the Paperwork Reduction Act
We estimate it will take you about 15 minutes to complete this form. However, you are not required to provide
information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions
regarding this form should be sent to the Terrorism Risk Insurance Program Office, 1425 New York Avenue, NW,
Washington, DC 20220. Do not send completed form to this address. Submit forms according to instructions
provided at
OMB No. 1505-0200 Expiration: July 31, 2017
TRIP 02B

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