st health using ur Passport Health Plan is yoyour g n i s u h t l hea one! hphone cell p pleased to offer SafeLink l l e c Passport Health Plan is pleased s i n a l P Wireless to its members. thSafeLink l a e H to offer FREE t r o nk sp i s L a e P f a S r e is a special, SafeLink Wireless offmembers. o t phones to all d No e s. of a SafeLink phone, s r a e e l b p m e Passport Health Plan members get all the same benefits m federal provides: o itscoststhat ecial,cost to learessnotadded reprogram a spbenefits: plus more!iThere for the following • A phone at no cost to you. • The ability to MAKE AND RECEIVE CALLS from your doctors, nurses, 911, family and friends. • Communication access 24 HOURS A DAY. Subject to cellular service availability. • Ability to participate in EDUCATIONAL programs. W ss is e l e r i W es: you! d k i n v i o r L • UNLIMITED text messages. e p f t a a S thoffers: SafeLink Wireless m a r g o r • FREE CALLS TO PASSPORT HEALTH PLAN MEMBER SERVICES will not count towards your 250 minutes. p al per month f• Upedto e250rminutes • Text Messages with health tips for you and your family • Up to 250 per month • The optionminutes to buy extra minutes at a DISCOUNT. Only $0.10 per extra minute.There are no added costs for inute. following benefits: xtra mthe onth so there are no surprises. •option A phone at no cost to you. er m pno a SafeLink phone, there are bills, 0.10 peIfr eyou run out of minutes, you can buy more •With The to buy extra s $ te ly u n in O . m T COUN Up to 250 s at a DIS Health Plan Member Services te inuCALLS • Unlimited messages. at minutes a discount. You•atocan always call 911 Passport at friends. no cost tostext if you at discount. Only mor a tr .you, even x • The ability MAKE AND RECEIVE from yourminutes doctors, nurses, 911, family and e y u free n to b and friend o ti y il p o m e fa h , T 1 • extra minute. per run10 outcents of minutes. rses, 91 octors, nu • Free calls to Passport's forto cellular the first st to you.A DAY. Subject r d4 service • Communication access 24coHOURS uavailability. o y o n m t o a fr e n S o CALL • A ph RECEIVE months!* lar service availability. NDTO • A phone atparticipate no cost to Ayou. E Member Services: K llu A M WAYS ENROLL HEALTH PLAN SAFELINK • Ability to in EDUCATIONAL programs. to ject to cePASSPORT y . SubTHE YIN A D A • The abilit S R HOU 1-800-578-0603 PHONE ess 24PROGRAM: • The ability to make tion accreceive icaand ms. n ra u g m ro m p o L C • A (these calls ,will not count UCATION calls from your doctors, nurses, in EDwww.safelink.com ate ip ne ic 1. Visit to apply online. rt a p to Passport Health Plan members get all the same benefits of a SafeLink phone, Link phoyour Ability fe • a towards 250 minutes). S a f o 911, family and friends. fits e n e b e m a benefits: plus more! There are no added costs forrsthe all the sand : theMessages tsText getfollowing ean application 2.n24 Fill out mail itg back enclosed envelope. b bene•fiusing with health m e in m • Communication access hours a day. w o ll la P fo h e lt th a r e fo H t r ts o s p o s c • UNLIMITED text messages. tips for you and 2your family. as cellular s. Pto (Subject service added 50 minute e noavailability.) 500 PROGRAM E for sec- D ASSISTANC guardian parent orfor ALL (*) REQUIRE LIFELINE ion of a ion informat the informat KENTUCKY on. Use VALID personal ON FOR applicati ONLY fill out this APPLICATI Please provide on. older to be 18 or will be rejected.N of your applicati FICATION on . You must member your applicati result in REJECTIO FULL CERTI do, Health Plan ncies will tion. If you informa and any discrepa with a Passport records your child’s is for families This offer 3. Do not use against public validated tions 1 and It will be FIELDS. 3 sy s ea ep st ION SECT 1 ation al inform an’s person tion. ’s or guardi te this applica comple Only a parent used to rary: o * should beaddres s is tempo Select if Please fill * * in the sections below if you are 18 years or older or applying of your on behalf * Contact ) Day/Year ______ Date (Month/ _______ Your Birth _______ _______ # _______ _______ _______ ED) ) _______ (REQUIR _______ Box Allowed _______ Plan member Code (P.O. t Health and Zip Name _______ City, State Member name of the Passpor Address, Enter full hlyys hly from above: th y th hlyyysont hly hly hly ont s Mont tess tes ontth Mont if different tes Mont minu minuminu Address lyy Mailing hly lyy nth hly lyynth hly Add Full nth tes tes tes Mont MontMont minu Phone Number * Last Name Digits of Last four MI child. First Name Social Security 55 512 1212 686868 0 050 050 25 2 50 25 2 25 2 hlyys hly hlyys nth hly hlyysnth hly tes Mon nth tes tes tes Mon tes Mont tes Mon Mont Mont minu minuminu minuminu s Plan Feature (check one) plan P PCA NH T N your Choose ** Local Calls Long Distance National Voice Mail no Additional Cost at l Cost Roaming e at no Additiona Free 911 Assistanc to Month additional from Month Destinations* 411 Directory s and redeem er Minutes Distance Plan Member if you purchase Carry-Ov nal Long Health However, delivery. for Passport s*** 100+ Internatio minutes Features next monthly •Exclusive Nationwide Text Message Services on your Member carry-over Unlimited s will not d Calls to Message out and Free Outboun ink.combe removed/wiped e months. Health Alert (TANF) e, Daily will at www.safel consecutiv Interactiv Families s available unused minutesover for three 2 Needy destination m: will for * List of choose this plan, minutes to obtain ce progra unused Assistance ts in order ** If you cards, all ty. statemen minutes to Terms and Conditions public assistan Temporary income make false your eligibiliin the following (SSI) o *** Subject and and share confirm Income ate rs who willfully address of FCC rules Plan will Security I particip at the same es a violation person. enroll. Custome t Health mental ers may another certify that Passpor live together ld rule constitut o Supple subscrib ls who benefit to I hereby by househo eligible . his or her of individua Medicare) one-perand onlythe program ion provided transfer l or group of the nd that benefit, Same as r may not barred from as any individua s. Violation using informatI understa this is a federal id (Not the to grantthat I provider and a Custome services. or can be Lifeline text message I refuse nd benefit, d service.imprisonment household is defined from multiple mobile health and if t. to me by I understa sferable supporte be sent ld. A Lifeline benefits in Voxiva’s by fine or tion is voluntary treatmen is a non-tran s that willto enroll me househo ® is a Lifeline Lifeline to obtain d to receive can be punishedone line per SafeLink and reminder to Voxivand that this authoriza Lifeline. or ability for onlyld is not permitte the benefit ion (PHI) health tips ment from of services, health services. provided above. is available d to FREE Health Informat terms. I understa mobile s. A househor’s disenroll S Lifeline e number for or coverage Voxiva’s iva.com/ expense Protected ically subscribe items.) receive Telephon my and result payment in the CustomeING SERVICE www.vox nt, at these automat to disclose found t I no longer will at the Contact I will be Policy benefits or enrollme ed withou TEXT MESSAG nd that Health Plan expire when from TracFone HEALTH tion will understa Passport ce with the Privacy be approv Health Plan nal offers below I I authorizeaccordan this authoriza promotio for Passport tion cannot in By signing Health Plan. be used my eligibilityI understand that special offers and Passport (Your applica ion will not affect at any time. ded tion. informat pre-recor this tion applica tion it will r of my authoriza this authoriza would like to receive and Date membe ing: if you may revoke then Sign another . carry your ION SECT o Medica , if I or ng program statements, of the follow . ng program tion of my (a) all ted qualifyi support qualifyiLifeline y to each in termina designa check off ate in the for will result ty of perjur ate in the above participlonger qualify to do so if I no if I no longer under penal and failure old, particip 30 days carrier, or at any time, r of my househ SafeLink® within from another Service ty for Lifeline LifelineSafeLink I, or a membe ed service I must notify ed eligibili to ly receive and that Lifeline support benefit my continu not current I underst obtains 30 days. my Lifeline to recertify old does ® within household required to transfer My Househ g false or to SafeLink I may be ze SafeLink providin ed service. address support and I authori ledge that my new Lifeline carrier carrier. and I acknow and ongoing , I will provide only one my initial (4) provide from another existing receive knowledge, my address with my to confirm old mayLifeline Service format; purpose of best of my If I change address provider benefits my househ e to the Medicaidproper mailingits agents for the my Lifeline my and that currently receives accurat te ion to SafeLink a and ) and ion from address to old I underst informat ble by law. will termina ion is true informat my provide of the program is punisha OR my househ and this and use applicat update with and/or ed in thisLifeline benefits tative to (1) Obtain ts herein; (3) (the administrator discuss and I underst tatives to tion contain y (USAC) my statemen tion to obtain appointed represen to verify trative Compan agency represen The informa informa duly nt required o fraudule m or its Adminis e social service e. felink.co Wireless l Service any records assistanc at www.sa ing SafeLink e; (2) access to the Universa and (5) authoriz Lifeline authoriz benefit; qualify me for be found You are for Lifeline assistancand address one Lifeline s that which can eligibility telephone number more thanbenefit program statements. Conditions, tion in my name,that I do not receive Terms and of the above participa Date verifying® verifying my t to SafeLink to each pursuan Wireless and agree offered elink.com service is tely affirm d www.saf SafeLink Code: requeste apply at , I separa Promo g below phone faster above where 02-5756 To get yourthe promo code By signin AM 1-866-9 10:03:10 and enter tion to: 8/20/2014 re Fax applica nt Signatu 97269-0009 31-2550 Applica kie, OR call 1-877-6 w Milwau ns please Box 220009 s® w PO For questio : 888-230-0790 k Wireles For Spanish tion to: SafeLin Mail applica o Check this box our phone. ! There a3.r Call SafeLink at 1-877-631-2550 to apply over the t towards y e n r u o o c m t o s n l lu il • FREE TO PASSPORT HEALTH PLAN MEMBER SERVICES willEnot countwtowards your 250 minutes. ages. • Ability topCALLS participate inD educational programs. S RVICES text mess MEMBER You MUST ION 3 I certify o o be checked off SECT Boxes MUST and understbenefits. o ILifeline o o E LAN • UNLIMIT HEALTH P u you can b , s * After 4 months, the• plan returns to 250 minutes.ou and your family te FREE C u in m t of ps for y you run ou you, even If h health ti . it s w e st tobuy s is e ocan r g c a p r s o s u n e s t M o a t With a SafeLink phone, there are no bills, so there are no surprises. If you run out of minutes, you more x n s e • T ere are Service RT your family SPOand • Text Messages with health tips for PASyou ALLS TO d 1 1191648.ind , so th mber ls so there arelthno Me nsurprises! no bilHealth With a SafeLink phone, there are If cost you torun out if you at a discount. You can always callon911 oreno Plan Member at no you, even e arebills, rPassport ea PlaServices H t th r , o e p 1-877-631-2550 s s h a p P k r o in L 1 1 fe 9 a ll S a a buy morenat of you You can always call 911 or Passport’sAN SAFELINK sc runminutes, out of minutes. Withcan alwaaydiscount. a c u o Y unt.cost to you, even if you run out of minutes. ORT HEALTH PL iscono Member Services at a dat 1191647.indd 1 8/20/2014 10:11:07 AM ASSP . inutesWAYS IN THE PHEALTH m f L o L t TO ENROLL IN THE PASSPORT PLAN SAFELINK O u R o N n E ru WAYS TO OGRAM: PHONE PROGRAM: R NE P e. PROGRAM E n for sec- ED ASSISTANC guardia parent orfor ALL (*) REQUIR LIFELINE tion of a tion l informa the informa KENTUCKY ion. Use VALID persona ON FOR applicat ONLY fill out this provide ion. APPLICATI . Please older to be 18 or will be rejected of your applicat IFICATION ON ion r. You must REJECTI FULL CERT your applicat Plan membe result in t Health tion. If you do, ncies will informa and any discrepa with a Passpor records your child’s is for families This offer 3. Do not used against public validate tions 1 and It will be FIELDS. 3 sy s ea p ste ION SECT 1 ation al inform ian’s person ation. t’s or guard ete this applic compl Only a paren used to rary: o * should beaddre ss is tempo Select if * * in the sections below if you are Last Name 18 years or * # Your Birth of your * First Name r Contact ar) /Day/Ye Date (Month Phone Numbe 3 ______ _______ _______ _______ _______ _______ Social Security _______ Digits of ) _______ r (REQUIRED) _______ Box Allowed _______ Plan membe Code (P.O. _______ rt Health and Zip r Name , City, State Membe name of the Passpo Address Enter full hlyys hly th t from above: y th hlyyysont hly hly hly ont s Mont tess tes ontth Mont if differen tes Mont minu minuminu Address lyy Mailing hly lyy nth hly lyynth hly Add Full Mont nth tes tes Last four 686868 RAM D for secUIRE PROG guardian (*) REQ NCE nt or for ALL on SISTA on of a pare mati infor NE AS informational LIFELI Use theVALI D pers Y on. UCKY icati ide ONL appl KENT this se prov ication. FOR fill out Pleayour appl ted. of r to TION N or oldebe rejec CTIO will PLICA be 18 MI child. 55 512 1212 REJE t AP lt in mus ication resu You appl ATION member.do, your cies will IFIC epan th Plan . If you discr CERT Healrmation any and port FULL a Pass ’s inforecords lic with r child lies nst pub fami use you agai not is for offer 3. Do validated This s 1 and be tion DS. It will FIEL sy s eatep s 0 050 050 25 2 50 25 2 25 2 hlyys hly hlyys nth hly hlyysnth hly tes Mon nth tes tes tes Mon tes tes Mont Mon Mont Mont minu minuminu TION SEC 1 tes minu MontMont minuminu Sel P PCA NH T N your Choose ** Local Calls l Long Distance Nationa Voice Mail no Additional Cost at al Cost Roaming Addition ce at no Free 911 l to Month y Assistan additiona from Month Destinations* 411 Director rs and redeem er Minutes Distance Plan Membe if you purchase Carry-Ov t Health ional Long However, delivery. s for Passpor s*** 100+ Internat minutes Feature next monthly •Exclusive d Nationwide Text Message Services r on your Member carry-ove Unlimite s will not d Calls to Message out and Free Outboun link.combe removed/wipedive months. Health Alert (TANF) will ve, Daily at www.safe consecut Interacti Families ns available unused minutesover for three statements, of ry to each if I the follow qualifying program. program, t. suppor ated qualifying or of termination ber e Nam 55 5 121212 e Num tact Con Phon 0500 050 225 225 22550 hlyyess hly tthly t hlyyess nth hly tthly Mon hlyyesnth hly t minutes tthly nth Mon t s utes Mon utes min min 8 68686 ** s ional Choo my I certify o o tand s. undersbenefit o ILifeline o o dd 1 1191648.in MI one) m addit Feature (check redee plan and ase se your purch nce if you ver, Dista l Calls Loca ry. Howe l Cost nal Long l Cost tiona Natio Mail tes delive tiona Addi (TANF) hly minu Voice ing at no ilies no Addi Month ons* in mont bers e at next th to inati Mem Roam tanc dy Fam r to obta 911 Assis from Mon nce Dest th Plan on your orde Free tory me -over for Nee ts in Heal Dista carry Direc r Minutes nce e incoand men port ages*** not 411 shar rules will nal Long -Ove and Assista e false state ess and for Pass Mess ices natio Carry out hs. of FCC gram: Inter Features e Text ber Serv iped e mont on. mak porary e addr tion ully e 100+ nwid ce pro ages m ved/w cutiv Mem sam a viola by Tem her pers willf stan idedthat ink.co be remo conse at thetitutes anot •Exclusivited Natio Calls toth Alert Mess I) o rs who .safel tes will for three d ther cons fit to lic assi ound Unlim on prov rstan t thisI over toged rule bene pub me (SS ll. 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I nta p of of the ntary men r may by text ble subs ram. pleme va’s mob is volu in treat l or groutionome eligi e. to me idua . Viola tion obta onlythe prog abov a Cust in Voxi s.) o Sup fit, andfrom iders oriza ty to indiv ided be sent me prov fit, and lth re) will enrollthis author abilith services. prov ed se item as any cert iple bene Hea ber s that va to ral bene ices, heal be barris defined mult ble Medica a fedecan num port I hereby d that out the nderto Voxi sfera of servmobile Pass e as hone d fits from rstan remi with tran ine is t or va’s ehol Telep and on (PHI)I undecoverage Sam benea nonLifelisonmen A housine roved or ive Voxi Contact ice. t the th tips mati rms. d. ine is heal th Infor m/te ent for er rece d servor impr ehol ive Lifel Lifel be app at the id (No FREE va.co orte long ine. one dica by fine per housto rece d to cted Heal.voxi nt, paym Lifel of my cannot TracF n I no itted llme shed ine supp cribe line ber www Lifel puni enro re whe offers from subs my Prote one perm t from d at lication mem my ® is acan be cally ose y foun fits orwill expi onlyd is notnrollmen al ther r app for ehol Link mati discl bene tion otion ion of Safebenefit able r’s dise ICES be autoPlan to cy Polic or ano . (You inat prom avail. A housome th Plan oriza the , if I SERV I will Health the Priva term Heal this auth offers and Cust ine is ram t. lication ING lt in . Lifel expeltnses port with port por d that SAG in the ram resu d that special e app Pass rdance for Pass : ng progsup and resu MES rstan T will Dat rstan prog lifyi ded orize acco bility unde ing will TEX w I unde ng and ice qua Lifeline to do so ecor . I LTH . I auth in eligi the lify for Serv follow qualifyi Sign time re HEA ing belo ive pre-r Link th Plan be used t my line ate in failu then at any Heal on will not affec to rece of the gnated participlong er qua By sign nts, tion ive Life to Safe , and port ld like it will oriza recebenefit eme Pass informati each time er if I no ve desi y wou auth tion to stat or any abo long or entl this oriza this at if you ) all curr Lifeline jury if I no ier, line g false in the auth revoke this box ( my s not idin k may of per icipate in 30 daysther carr ty for Life sfer oing prov ck off ld doe o Chec alty ong to tran ld, part ® with from ano eligibili e that seho ST che l and provide pen days. Link edg of Hou seho MU ed ice er 30 (4) Link initia owl ose TION My e Safe in at; tinu You und of my hou SEC ice. rm my formthe purp Link fy Safeted serv I ackn ® with tify my con serv I authoriz 3 t notisuppor Link , and to confiaddressts for on to Safe ted rtify I cer a member ider I mus to Safe suppor ier and ier. mati wledge prov mailing its agen to rece that Lifeline ress I, or ins linether carrting carr and ide infor icaid proper ired add my kno Lifeano o erstand t of new to a program) or prov ld obta my Med one be requ I und my exis the bes ess and/ ide my ive onlyice fromwith on from addr of the o househo and I may to . ss with prov mati ate my rator rate law. rece Servbenefits efits erst discu infor , I will by accu use (3) upd administes to I undline ben line ld mayLifeline ress ble and in; and tativ Life (the isha in seho ives my o Life C) here m esen my add is true k.co nge my hou y receinate lication efits is pune to (1) Obtamentspany (USAcy repr felin that currentl term If I cha ben tativ y my state app ld e Com ice agen will www.sa e. o serv rativ erstand seho this in this Lifeline represen d at to verif inist social assistanc in ed hou and I und inted ired Adm erst be foun o OR my ents. containto obta appords requService authorizeLifeline e com I und l tem duly for tionrmation Dat link. ch can and ersa and (5) rma or its any reco .safe ested ify me fit; ve sta Univ ns, whi info nt info less ss wwwre requ abo The ditio Wire acce to the ine benethat qual y at ess the Con Link e; (2) r appl e whe rams o fraudule addr one Lifel 014 abov h of s and prog ng Safe tanc e faste e: 8/20/2 orizi ine assis ber and e thanbenefit Term Cod phon o code to eac mor in Link yourthe prom e num are auth Lifel Promo tion Safe agree r hon receive You bility for To get t to icipa ente 56 not and uan eliginame, telep and I do my part 2-57 purs affirm my ying that ying 6-90 red tely 009 offe verif less® verif to: 1-86 69-0 ice is separa Wire itions of se all unus you Cond , ate * List choo and you tes cards s ** If confirmI particip minu ct to Term will t Plan ify tha *** Subje TION SEC 2 o Me a 1 2 off Boxes MUST be checke d off 3 (a) all check off your * checked ION SECT as Medic this box lf of on beha * individu one-pertransfer his and onlythe program al or group of tion provide n of the and that benefit, from informa er may not the Same this rs. Violatio . I underst e using is a federal as any individu can be barred to grantthat I provide and a Custom aid (Not Lifeline text messaghealth services is defined I refuse nment or benefit, o Medic ed service. from multiple mobile to me by y and ifnt. I understand or impriso old. A household sferable support be sent in Voxiva’s is voluntar d by fine Lifeline benefits is a non-tran househ rs that willto enroll meauthorizationto ® is a Lifeline obtain treatme Lifeline can be punishe one line per ed to receive SafeLink and reminde . ability to Voxiva that this Lifeline. permitt the benefit e for only above. tion (PHI)I understand e of services, orhealth services health tips old is not llment from Informa provided is availabl ed to FREE s. A househer’s disenro d Healthxiva.com/terms.t for or coveragVoxiva’s mobile Lifeline ) ne number expense tically subscrib my Protecte and result in the Custom ING SERVICES at www.vo ent, paymen these items. longer receive at the Contact Telepho will will be automa or enrollm when I no e Plan to disclose found without TEXT MESSAG and that I t Health the Privacy Policy from TracFon Plan benefits will expire approved HEALTH underst Passpornce with t Health authorization onal offers below I I authorizeaccorda cannot be this in y for Passpor By signing and promoti and that Health Plan. application my eligibilit will be used I underst Passport special offers (Your tion affect time. rded not ation. any pre-reco this informa applic ation at ation it will of my authoriz like to receive and Date this authoriz member ing: if you would may revoke then Sign another o Check lying app be MUST Boxes Passport 2 r or olde * * m: will carry for Needy to obtain nce progra Assistance nts in order ity. stateme public assista Temporary income make false your eligibil the following e (SSI) o and and share willfully will confirmparticipate in address of FCC rules ers who ty Incom I al Securi r at the same Health Plan person. enroll. Custom tes a violation ers may constitu to another certify that live togethe Supplement old rule subscrib als who I hereby are) o d by -househ or her benefit eligible . your destinatio * List of choose this plan, minutes unused s ** If you cards, all minutes to Terms and Condition *** Subject ION SECT s or year ____ ear) ____ you ay/Y ____ w if th/D ____ belo (Mon ____ ions Date ____ sect ____ Birth in the ed) ____ Your se fill ____ Allow Plea Box ____ D) ____ e (P.O. UIRE ____ # e rity Zip Cod ____ ber (REQ Nam and ____ hlyy s hly al Secu thly tth Last mem hlyyysont hly State ____ y tthly th s utes Soci Mon hlyont hly thly tth s utes City, min ____ lth Plan Mon ts of ontutes Mon min Digi ress, ____ min four ____ port Hea ve: Add Last e ____ Pass abo lyy Nam e of the hly from tthly lyy nth hly ber ynth tthly utes ly rent Mon hly tthly nth min Mon utes Memr full nam if diffe Mon utes min min ress Ente ing Add Mail Full Add are 18 pply onlin a to m o k.c WAYS v felin3 .saapply wto 1. Visit www.safelink.com online. closed en n e e th g 1. Visit ww ack usin ail it bget to enroll and m d n a n o plicaittiback using the enclosed envelope. an apmail 2. Fill out an application and hone. 2. Fill outyour FREE phone: over the p ly p p a to 550 -877-631-2 1 t a k in L 3. Call SafeLink at31-877-631-2550 to apply over the phone. . Call SafeVisit www.safelink.com tion rma info sonal tion. lica n’s per rdia this app or gua plete ent’s com :o a par used to porary Only be tem is ress * should add ect if es one) Plan Featur plan (check PHO H TP N PCA N Please fill g on behalf applyin older or 10 AM 10:03: I 972 lication ow, ie, OR app auk Fax 50 w Milw ature 1-25 009 220 Sign 7-63 1-87 licant PO Box s® w se call 0 -079 ns plea Wireles stio -230 Link que : 888 For to: Safe nish Spa lication For l app Mai Link Safe serv ing bel By sign App d 1 48.ind 11916 1-877-631-2550 1191647.indd 1 1 91647.indd 11 MARK-40626 APP_9/23/2014 1-2550 1-877-63 3 to apply online. Fill out an application and mail it back using the enclosed envelope. Call SafeLink at 1-877-631-2550 to apply over the phone. 8/20/2014
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