Form Cms-379 - Financial Statement Of Debtor Page 4

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33. Is there any likelihood you will receive an inheritance?

Yes, from whom?

34. Do you receive, or under any circumstances, expect to receive benefits, from any established trust, from a claim for compensation or

damages, or from a contingent or future interest in property of any kind?

Yes, explain below

With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or 5 years imprisonment) and

with knowledge that this financial statement is submitted by me to affect action by the Department of Health and Human Services, I certify

that I believe the above statement is true and that it is a complete statement of all my income and assets, real and personal, whether held in

my name or by any other.

Date

Signature

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 0938-0270. The time required to complete this information collection is estimated to

average 2 hours per 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:

CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-379 (07/07) EF 07/2007

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