Golden Horizons.

correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed An equal opportunity employer. Letter ID: IS7N REVISE D09/13/2021 Golden Horizons March 26, 2026 Page 2 pursuant to this survey: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 1620 - 144g.70 Subd. 2 (c-E) - Initial Reviews, Assessments, And Monitoring - $3,000.00 The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $3,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee( s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with · the specific statute( s). CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you Golden Horizons March 26, 2026 Page 3 may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/ or investigation process. Please fill out this anonymous provider feedback questionnaire at your conv enien ce at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your inpu t is import ant to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan. winkelmann@state. mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 CLN PRINTED: 03/ 26/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30345 03/ 06/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1790 COLLEGEWAY GOLDEN HORIZONS WORTHINGTON, MN 56187 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G. 08 to 144G. 95, these correction orders are far-left column entitled "ID Prefix Tag. " The issued pursuant to a survey. state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators' findings is the INITIAL COMMENTS: Time Period for Correction. SL30345016- 0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On March 2, 2026, through March 6, 2026, the STATES, "PROVIDER' S PLAN OF survey at the above provider and the following FEDERAL DEFICIENCIES ONLY. THIS correction orders are issued. At the time of the WILL APPEAR ON EACH PAGE. survey, there were 35 residents; 35 receiving services under the Assisted Living Facility with THERE IS NO REQUIREMENT TO Dementia Care license. SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. 1620: An immediate correction order was issued on March 5, 2026, at a level 4/Isolated (J) . THE LETTER IN THE LEFT COLUMN IS The licensee took immediate action; however, the USED FOR TRACKING PURPOSES AND scope and level remains at J. REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 110 144G. 10 Subdivision 1a Assisted living director 0 110 SS= C license required LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7E4O11 If continuation sheet 1 of 49 PRINTED: 03/ 26/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The facility neglected the resident when the facility failed to monitor and assess the resident for pressure sores. The resident was found to have an unstageable pressure wound with a foul odor upon transfer to another facility. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The facility documented the resident’s refusals of repositioning, incontinence care, bathing and he had a sore and reddened coccyx. After the resident was transferred to a skilled nursing facility and concerns were raised that the resident had a more advanced wound than what the facility reported, the facility provided detailed wound tracking records and handwritten edits to the previous assessments. However, details regarding the care of the wound and the wound itself was not evident during staff interviews. Staff members did indicate that assessing the wound was difficult because of the resident’s refusal to lay down in bed for care. The ALF’s description An equal opportunity employer. of the wound is not consistent with the SNF’s description or photos of the wound on the same day but the situation was complicated the resident’s refusal of cares. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included a review of the resident’s medical records, as well as other records of residents with pressure wounds at the facility. Facility incidents, recent hospitalizations and policies were reviewed. The resident resided in an assisted living facility (ALF). The resident’s diagnoses included multiple sclerosis (MS) and neurogenic bladder (the inability to control the bladder). The resident’s service plan included assistance with all activities of daily living which included mobility and transfer assistance. The resident’s assessment indicated he was oriented and could make his needs known. When the resident transferred from the ALF and admitted to a skilled nursing facility (SNF), he e had bottom area of pain for at least two weeks that was bad enough he was not able to sit on his bottom and had to lean to the side to offset the pain. Review of the SNF nursing assessment records indicated that upon admission, the resident had a 2 centimeter (cm) by 2 cm open area which appeared to be tunneling. Review of the admission wound photos clearly showed a wound which is open with tunneling. The resident’s ALF record indicated staff members documented the resident’s refusals with toileting, incontinence, and hygiene care in the months prior to the resident’s discharge. The records did not indicate if any pressure relieving devices or interventions were in place, but indicated the risks of the refusals were discussed repeatedly with the resident. The resident’s ALF wound care tracking record indicated the wound was dressed daily and assessed weekly, yet the resident refused to lay in bed. On the day of the transfer to the SNF, the ALF nurse documented the wound to be red and slightly bleeding. During an interview, an unlicensed ALF caregiver stated the resident would frequently refuse incontinence care, repositioning in his chair and lay in bed. During interview, the ALF nurse stated the resident became weaker and could not offset his weight on his own. The nurse stated the resident slept in the recliner chair and refused to lay in bed. The resident refused incontinence care and with concern for skin breakdown, it was advised that a Foley catheter be placed, but the resident declined the option and standing orders for wound care were followed for the resident. The nurse stated assessments were done while the resident was toileted except for one time they were able to lay him down in bed. The nurse stated the sore had slight bleeding and was not open the day he discharged from the ALF. During interview, a nurse from the SNF, stated they were told the resident had a sore on his bottom that was not open. When the resident admitted, the wound was a stage four tunneling wound on his sacral area. The nurse stated that the ALF did not provide any wound care documentation or communication about an advanced pressure wound. During interview, a family member stated she was not made aware of the resident’s risk of pressure sore wounds or that the resident had a sore on bottom that was forming. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: No action taken. The resident transferred to a higher level of care at the SNF. Action taken by the Minnesota Department of Health: No action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/19/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30345 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1790 COLLEGEWAY GOLDEN HORIZONS OF WORTHINGTON WORTHINGTON, MN 56187 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On August 9, 2023, through August 10, 2023, the investigation of the following complaints: HL303454263M/HL303457216C and HL303457325M/HL303453872C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z22911 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The facility neglected the resident when the facility did not complete wound care and the resident’s wound became infected. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The facility completed dressing changes for the resident’s wound. Although the dressing changes may have not been done consistently and the wound worsened, the bone did not become infected. Other factors may have contributed to the wounds progress. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of facility policies and records of residents who received wound care services. Also, the investigator observed staff providing direct resident care. An equal opportunity employer. The resident resided in an assisted living facility. The resident’s diagnoses included diabetes with neuropathy (loss of feeling in lower extremity) and a chronic heel ulcer. The resident’s service plan included assistance with medication management, glucose monitoring, wound care, bathing, housekeeping, and laundry. The resident’s assessment indicated the resident had a chronic heel ulcer that required dressing changes under the guidance of the wound clinic. The resident had progressive weakness and was unable to stand without bearing weight on her heels. The resident required staff reminders to not self-propel in the wheelchair as this would put pressure on the heels and to keep feet elevated while in the recliner. The progress notes indicated the resident was seen in the wound clinic weekly for wound care. The investigation included a review of wound clinic notes spanning more than one year. The notes indicated that over this period the wound improved and worsened again multiple times. Over that time, the resident reported that wound dressings were not applied correctly or consistently. The provider’s notes indicate the wound clinic followed up with the facility when the resident raised concerns about wound care. The same documents indicated the resident reported she at times propelled herself using her feet in the wheelchair and the wound clinic encouraged her to not do so. The resident’s service delivery records indicated wound dressing changes were scheduled every morning. The records indicated the changes were signed off as completed but sometimes it was signed off as completed later in the day. During an interview, an unlicensed caregiver stated the dressing changes were to be done daily although the resident would want to wait until after her shower to change it so the wound care was at times delayed. During interview, a facility nurse stated the resident’s wound was assessed weekly on her bath days and there may have been signs of cellulitis but not specifically infection. During an interview, another nurse stated the resident did not always alert staff when the dressing fell off or needed to be replaced. During interview, the wound clinic provider stated the resident’s wound worsened but not to the point of infection. During an interview, the resident stated her doctor was concerned about the wound not being redressed daily. She stated the dressing changes sometimes did not get done in the morning and when the next shift staff came in, they did not want to change the dressings. Other than that, it was a good place to live. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: No. Alleged Perpetrator interviewed: Not Applicable. E Action taken by facility: No action taken. Action taken by the Minnesota Department of Health: No action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 12/19/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30345 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1790 COLLEGEWAY GOLDEN HORIZONS OF WORTHINGTON WORTHINGTON, MN 56187 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On August 9, 2023, through August 10, 2023, the investigation of the following complaints: HL303454263M/HL303457216C and HL303457325M/HL303453872C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z22911 If continuation sheet 1 of 1

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation: The facility neglected the resident when the facility did not intervene or report abuse by a family member. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While the resident did have some injuries these were attributed to a fall. The investigation did not find evidence of abusive acts or interactions directed towards the resident. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator contacted law enforcement for police an investigation report and the hospital for the resident’s medical records. The investigation included review of facility policies and facility resident records. Also, the investigator observed visitor and staff interactions with current residents. An equal opportunity employer. The resident resided in a secured assisted living memory care unit. The resident’s diagnoses included late onset Alzheimer’s disease, cardiac disease, and osteoporosis. The resident’s service plan indicated the resident required assistance with all activities of daily living, bathing, dressing, meals, and medication management as well as safety checks and frequent supervision. The resident’s cognitive assessment indicated the resident had difficulty expressing thoughts or word finding at times and may not be able to report abuse or neglect secondary to her dementia diagnosis. The resident’s individual abuse prevention plan (IAPP) indicated that staff were to watch for signs and symptoms of abuse or neglect and report to administration if abuse was suspected. The nursing documentation note in the resident’s file indicated a police officer made a visit to the facility for a complaint of abuse and met with the resident’s family and facility staff regarding the complaint. The police report indicated the police department received a report that the resident was in the hospital as a result of injuries possibly due to abuse by her husband. Interviews obtained by the officer indicated family and a nurse believed the injuries were from a recent fall. Another staff interviewed by the officer, stated that the husband could be aggressive with the resident at times but had not witnessed abuse or harm. The report summarized there was no evidence that abuse occurred. The resident’s hospitalization record indicated the resident had injuries that included displaced ribs, a displaced pelvic bone and chronic spine compression fractures all believed to be consistent with fall injuries. The records did not mention suspected abuse. During an interview, a facility staff person stated she never witnessed any abuse toward the resident and only heard the allegations second hand from another facility staff person. During an interview, a nurse stated it was brought to her attention a vulnerable adult report had been made. She stated she was personally unaware of any suspected abuse and knew of no staff members who knew of such an occurrence. The nurse stated she understood the husband to be caring and helpful when staff members involved him in the resident’s cares. During an interview, a family member stated the resident was in the dementia unit at the time and if anyone touched the resident to do anything, use the restroom or help with a shower for example, the resident would scream out. He stated that the resident’s injuries were consistent with a fall and was not aware of any abuse. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, the resident was deceased. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. e Action taken by facility: No action taken. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 11/03/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30345 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1790 COLLEGEWAY GOLDEN HORIZONS OF WORTHINGTON WORTHINGTON, MN 56187 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On August 9, 2023, the Minnesota Department of Health initiated an investigation of complaint HL303452903M and HL303454896C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1D6H11 If continuation sheet 1 of 1