Form Cms-10175 - Electronic File Interchange Organization (Efio) Certification Statement Page 3

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ATTENTION: READ THE FOLLOWING PROVISION OF FEDERAL LAW CAREFULLY BEFORE SIGNING.

Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly

and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false,

fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing

the same to contain any false, fictitious or fraudulent statement or entry, shall be subject to fines and/or

imprisonment (18 U.S.C. Section 1001).

To the best of my knowledge and belief, all data in this application are true and correct, and the governing

body of the EFIO has duly authorized the signature of this document.

First Authorized Official – Full Name (Print)

Title/Position

Telephone Number

Legal Business Name of EFIO

“Doing Business As ” Name of EFIO

Business Address of EFIO

First Authorized Official Signature

Second Authorized Official – Full Name (Print)

Title/Position

Telephone Number

Legal Business Name of EFIO

“Doing Business As ” Name of EFIO

Business Address of EFIO

Second Authorized Official 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 0938-0984. The time required to complete this information collection is estimated to 3 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA

Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-10175 (08/06) EF 09/2006

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