4.70.1 Affordable Care Act (ACA) Hospital Compliance Review

Manual Transmittal

October 5, 2018

Purpose

(1) This transmits new IRM 4.70.1, TE/GE Examinations, Affordable Care Act (ACA) Hospital Compliance Review.

Material Changes

(1) Exempt Organizations Compliance Area (EOCA) was dissolved. This IRM was extracted from IRM 4.75.9 and updated to address ACA Hospital Compliance Reviews.

Effect on Other Documents

This obsoletes IRM 4.75.9, Exempt Organizations Examination Procedures, Exempt Organizations Compliance Area (EOCA), dated August 9, 2016.

Audience

Tax Exempt and Government Entities
Government Entities and Shared Services
Compliance, Planning & Classification
Classification and Case Assignment

Effective Date

(10-05-2018)

Justin L. Abold-LaBreche
Director, Government Entities and Shared Services
Tax Exempt and Government Entities

Program Scope and Objectives

  1. This IRM contains Exempt Organizations (EO) procedures for Affordable Care Act (ACA) 501(r) Hospital Compliance Reviews.

  2. It sets up guidelines for the ACA Hospital Review Group when performing compliance reviews of tax-exempt organizations operating a licensed facility to see if they are following the requirements in Section 501(r) of the Internal Revenue Code (IRC) and IRC Section 501(c)(3) as illustrated by rulings such as Rev. Rul. 69-545,1969-2 C.B. 117.

  3. The ACA Hospital Review group is the intended audience for these procedures/instructions.

Background

  1. Section 501(r)(1) provides that hospital organizations must satisfy certain additional requirements to be described under section 501(c)(3). A “hospital organization” is an organization that operates a facility which is required by a State to be licensed, registered, or similarly recognized as a hospital.

  2. Section 501(r) imposes four main statutory requirements. A hospital organization must:

    1. At least once every three years, conduct a Community Health Needs Assessment (CHNA) and adopt an implementation strategy to meet the health needs identified in the CHNA,

    2. Establish a written Financial Assistance Policy (FAP) and an emergency medical care policy,

    3. Limit charges for emergency and other medically necessary care provided to individuals eligible for FAP assistance, and

    4. Abstain from engaging in extraordinary collection actions until the organization has made reasonable efforts to determine whether an individual is eligible for FAP assistance.

  3. Based on Public Law 111-148 (Mar. 23, 2010) – Sec. 9007(c) EO Examinations shall review at least once every 3 years the community benefit activities of each hospital organization to which section 501(r) of the Internal Revenue Code applies.

Authority

  1. The Patient Protection and Affordable Care Act (ACA), Public Law 111-148, added IRC 501(r)

  2. Public Law 111-148, Section 9007(c), Review of Tax Exemption for Hospitals, states "The Secretary of the Treasury or the Secretary’s delegate shall review at least once every three years the community benefit activities of each hospital organization to which section 501(r) of the Internal Revenue Code (as added by this section) applies."

Responsibilities

  1. ACA Hospital Review cases are controlled, monitored, worked, and stored in the Reporting Compliance Case Management System (RCCMS).

  2. The activity screens are viewable based on the role or permissions assigned within RCCMS.

  3. Each level of the process completes the appropriate tabs:

    • Revenue agents (RA) complete the Organization, RA Conclusion, and Facilities/Surveys tabs.

    • Revenue Agents in Charge (RAIC) complete theRAIC Review (1 of 2) and RAIC Review (2 of 2) tabs.

    • Manager completes the Triage tab.

    • Tax Examiners (TE) complete the Review tab.

    • All employees input information on the Closing and Chronology tabs.

Program Management and Review

  1. Compliance Planning & Classification (CP&C) / Classification & Case Assignment (C&CA) does statistical reporting for the ACA Hospital Review groups.

  2. Special Review: Review Activity Records are selected with the same criteria (algorithm) as examination cases. Special Review is responsible for quality review.

Program Controls

  1. The ACA Universe is a changing population due to hospital mergers, consolidations, terminations, and new determinations. Planning and Monitoring (P&M) maintains it.

  2. The following sources maintain the universe population:

    • Returns Inventory and Classification System (RICS) queries:

      • Form 990 Part IV Question 20 ‘YES’ Responders with Schedule H

      • Form 990 Part IV Question 20 ‘NO’ Responders with Schedule H

      • Foundation Code 12 - to identify governmental hospitals

    • Medicare/Medicaid database research

    • State licensing websites - official governmental databases

    • RCCMS - Information Factory - previous reviews

  3. The population is divided into three segments to ensure that all hospitals are reviewed every three years. Case selection is based on the three-year cycle. The P&M staff imports all cases into RCCMS.

  4. ACA Activity Records within RCCMS require approved roles and permissions to access.

Terms Definitions Acronyms

  1. Acronym Definition
    AC Activity Code
    ACA Affordable Care Act - also known as the Patient Protection & Affordable Care Act, Public Law 111-148
    C&CA Classification & Case Assignment
    CCR Case Chronology Record
    CHNA Community Health Needs Assessment
    CP&C Compliance Planning & Classification
    EIN Employer Identification Number
    EO Exempt Organizations
    FAP Financial Assistance Policy
    GE Government Entities
    GECU Government Entities Compliance Unit
    IDRS Information Document Request System
    IRC Internal Revenue Code
    MEF Modernized E-File
    PC Project Code
    P&M Planning & Monitoring
    RA Revenue Agent
    RAIC Revenue Agent in Charge
    RCCMS Reporting Compliance Case Management System
    RICS Returns Inventory Management System
    TC Transaction Code
    TE Tax Examiner
    TE/GE Tax Exempt & Government Entities
    TIN Taxpayer Identification Number
    UBI Unrelated Business Income

ACA RCCMS

  1. RCCMS establishes Hospital Compliance Reviews.

  2. ACA Hospital Review Group’s purpose is to complete compliance reviews of 501(c)(3) organizations who operate a facility required to be licensed as a hospital by a State to see if they are following the requirements outlined in Section 501(r) and Section 501(c)(3) as illustrated by rulings such as Rev. Rul. 69-545, 1969-2 C.B. 117.

Activity Record

  1. The activity screens are viewed based on the role/permissions (for example: RA, TE, RAIC, group manager, etc.) assigned within RCCMS. At certain levels, tabs may be viewable but are read only.

  2. The Hours per Case grid in the Closing tab tracks hours spent on the case instead of the Case Chronology Record (CCR).

  3. The CCR tracks any delays in working the case.

  4. Return information is populated to the activity records from RICS.

Case-Establishment

  1. RCCMS establishes ACA Hospital Review case work using the WebRics program.

    Note:

    Programming in WebRics automatically assigns the ACA Activity records to group 7728 unassigned inventory based on ACA Bulk Load.

  2. RCCMS adds cases as needed to ensure the pre-populated return information is from the most current return filed.

Tax Examiner Case-Building

  1. An ACA TE located in C&CA completes case building in RCCMS.

  2. The manager assigns each case to the TE inventory in Status 02.

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  4. The TE completes the following required fields for each case on the ACA Activity screens in RCCMS:

    • TIN Indicator

    • Review Year

    • Phase

    • Wave

    • MEF Check Box – Verify return information coincides with return included in case file

    Note:

    You must ensure the fields are 100 percent correct because once you establish the case, you cannot change the fields.

  5. The TE sets Validate for to Establish, and establishes the case.

  6. Based on manager direction, the TE transfers the established cases to the working groups.

ACA Manager(s) Case Assignment

  1. The group manager will accept a case transfer and assign it to an RA to complete the review.

  2. The group manager (or his/her delegate) assigns each case.

  3. Each case with multiple hospital facilities (three or more) is assigned to a Grade 13 RA. Alternatively, a case with multiple hospital facilities can be assigned to a Grade 12 RA as developmental work, as long as this work does not exceed more than 20 percent of his/her total inventory or time expenditure.

Revenue Agent Activity Record

  1. The RA can access the Organization, RA Conclusion, Closing, Facilities/Surveys and Chronology tabs.

  2. The RA’s inbox (within RCCMS) will receive a message that a case has been added to his/her inventory.

  3. On the Organizational tab, the RA will complete:

    • Org Type

    • Tax Period

    • Agent

    • 501(c)(3)

    • State Licensed Facility

    • Schedule H Filed

    • Part V Sec A Complete

    • Part V Sec B Included

    • State Filings Reviewed

    • Part of Group Return

    Additional input may be required based on the selections, such as:

    • Group Return TIN

    • State/Local Filing Documents Reviewed

    • Government Entity or Indian Tribal Source

    .

  4. The required fields will highlight in red when you select Validate for Close.

  5. On the RA Conclusion tab, the RA will complete the following fields:

    • Issues Identified

    • Issues Identified Explanation

    • RA Predominant Issues Identified

    • RA Select Predominant Issues

    • Changes to Org Structure

    • RA Recommended Disposal Code

    • Final Conclusion

  6. Additional fields that may be required are:

    • Non-ACA Compliance Check

    • Non-ACA Examination

    • ACA Examination

    • RA Other Predominant Issues Explained

    • Valid EIN

    • Org Structure Explanation

  7. On the Closing tab, the RA will complete:

    • Sources

    • Hours per Case. In the grid, select role, name and input the hours spent on the case.

  8. Additional fields that may be required are:

    • Other Sources

    • IRC 4959Liability

    • Failed Facilities

    • Form 4720Filed

  9. The bottom section of the tab Closed By is automatically completed when the case is closed.

  10. On the Facilities/Surveys tab, create and verify Facility Sub-records and Survey completion.

    Note:

    Facilities will be created based on the information obtained from the Form 990, Schedule H. Every facility record must be reviewed and updated with the required information.

  11. The New Facility button allows the addition of Facilities Sub-records identified during the review process but not included in the Schedule H.

Revenue Agent Facility Sub-record

  1. On the Facility Sub-record, the RA will verify or complete applicable fields, update any if necessary, and indicate if the facility should be included in the survey.

  2. The RA must complete the following fields:

    • Include in Survey

    • Valid State License

    These fields allow the system to know whether to include the facility in the survey.

  3. Once the Facility Sub-record is updated, it must be included in the survey.

    Note:

    Even though it may appear that you can create a survey (i.e., the button is available), the RA cannot create and save the survey unless he/she selects Validate for Update to indicate that the organization is a 501(c)(3), subject to 501(r), and has a facility to survey; otherwise, an error will occur, and the RA cannot finalize the survey.

Revenue Agent Surveys

  1. After completing the activity screens, the RA will then complete the surveys.

    Note:

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  2. The surveys are on the same tab as the Facility Sub-records. Two buttons are positioned at the bottom of the screen to create the surveys. The questions are set up in sections which apply to each of the issues.

  3. The RA must select the button for the survey that he/she is completing.

  4. The RA will answer the survey questions, either by selecting an option from the drop-down box corresponding to each question, by selecting the appropriate check box, or by entering a response when a given question calls for one.

Examinations Referrals Non-ACA/ACA Issues

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  3. If an examination is warranted on a 501(r) issue, complete an ACA Form 17, ACA Hospital Review 501(r) Referral Coversheet, to be included in the case file. (Exhibit 4.70.1-1)

  4. If an examination is warranted on a Non-501(r) issue, complete an ACA Form 16, ACA Hospital Review Non-501(r) Referral Coversheet. (Exhibit 4.70.1-2)

Non-501(r) Compliance Check Referrals

  1. During the review, you could identify potential 501(r)(4) and non-501(r) issues that can be addressed in a compliance check.

  2. Compliance check referral issues include, but are not limited to:

    • Financial Assistance Policy (FAP) requirements per 501(r)(4) missing or incomplete

    • Any required schedules that are not attached, or

    • Any information that is missing from a required return or schedules

  3. If a case should be referred for a 501(r)(4) or non-ACA compliance check, complete ACA Form 12, ACA Compliance Check Referral Coversheet, to be included in the case file. (Exhibit 4.70.1-3)

Dual Status Hospitals

  1. Dual Status entities are governmental hospital organizations that have received a determination letter from the IRS that they are exempt under section 501(c)(3) and that also qualify as an affiliate of a government unit as described in Rev. Proc. 95.-48.

  2. The RA must verify a government hospital organization using the employment code or Rev. Proc. 95-48,1995-2 C.B.418 filing requirement 990-14.

  3. During the review, if the governmental status of the organization is not clear, the RA will contact the group manager who will contact the Government Entities (GE) analyst in the Government Entities Compliance Unit (GECU) to determine whether the organization is a government entity.

  4. The manager will notify the RA of GE’s decision. The RA must then update the case, notating the decision in the conclusion.

Revenue Agent in Charge (RAIC) Review

  1. The RAIC will review all cases closed with a disposal code other than Disposal Code 751 (Hospital - Review Completed).

  2. The RAIC can access these tabs in RCCMS: Organization, RA Conclusion, Closing, RAIC Review (1 of 2), RAIC Review (2 of 2), Facilities/Surveys and Chronology. The Organization, RA Conclusion and Facilities/Surveys tabs will be read only.

  3. The case will be assigned to the RAIC in Status 20 (Review Evaluation).

  4. The RAIC will review the activity record to verify that all required fields are complete and accurate.

  5. The RAIC will also review the surveys to verify they are complete and accurate based on the case file documentation.

  6. The RAIC will ensure the RA has included all documentation related to their conclusion, for example, copies of:

    • Community Health Needs Assessment (CHNA)

    • Financial Assistance Policy (FAP)

    • Implementation Strategy

    • Audited Financial Statement

  7. If the RA recommended a compliance check or examination referral, the RAIC will determine if the action is appropriate.

  8. If there is an issue with the case, the RAIC will complete the ACA Reviewer Feedback Form as appropriate.

  9. On the RAIC Review (1 of 2) tab, the RAIC will complete all fields except for the RAIC Closing Review Date, which auto-populates.

  10. On the RAIC Review (2 of 2) tab, the RAIC will complete recommendations and summarize the results of the review.

    Note:

    If feedback, correction or advisory is recommended on tab 1, the Manager Feedback Approval field will become available for the manager to complete.

Manager (Triage) Review

  1. Cases closed as a referral for examination or compliance check will be assigned to the manager for "Triage" review.

  2. The manager will review all cases before closing and approve the cases for final closing evaluation.

  3. The manager can access these tabs in RCCMS:Organization, RA Conclusion, Closing, RAIC Review (1 of 2), RAIC Review (2 of 2), Triage, Review, Facilities/Surveys and Chronology. The Organization, RA Conclusion, Closing, RAIC Review (1 of 2), and RAIC Review (2 of 2) tabs will be read only.

  4. The manager will self-assign the case in Status 77 (Manager Review).

  5. If the manager agrees with the RAIC’s assessment and a correction is needed, the manager will return the case to the RA who originally worked it.

  6. The manager will complete the required fields on the Triage tab once the review is completed.

Manager Closing Evaluation

  1. Closure requests are received in RCCMS’ unassigned message inbox from the RA (Status 10) and RAIC (Status 20).

  2. All cases ready for closure must go through the Status 51 (Case Evaluation) before being transferred to the Case Assignment Group for final closing.

  3. The manager will assign each case to inventory update status code.

  4. The manager will verify that all required fields in the activity records are completed based on the status codes.

  5. The manager will verify that surveys are finalized based on the disposal code.

  6. On the Closing tab, the manager will verify that the RA/RAIC entered his/her time.

Final Close / Closing Unit

  1. All ACA Hospital Review cases are transferred to the ACA Case Assignment Group for final closing.

  2. The Case Assignment Group employee will complete the final close by verifying that all required fields within RCCMS are complete and then select Status Code 90, Final Close.

  3. The Case Assignment Group employee will input the required transactions on IDRS:

    • TC 971, AC 318 on the tax year of the review

    • Hospital Identifier on the EO Submodule of IDRS, if not already there

ACA Form 17- ACA 501(r) Exam Coversheet

ACA 501(r) Issue Examination Form
TO: Referrals/Classification
RE: PC 8015 ACA Hospital Review Referrals
Organization Name & Address:  
EIN:  
MFT:  
Tax Period:  
Statute of Limitations:  
Principle Issue Code(s):  
Source Code: 96 (Review of Operations)
Activity Code: 344 (Hospital/Other Health Services)
Tracking Number 1004 (Emerging Issue)
Project Definer Code 87 (last 2 digits ACA Review Phase & Wave)
Description of issue being referred:
 
 
 

ACA Form 16 Non-501(r) Referral Examination Form

ACA Non-501(r) Examination Referral Form
TO: Referrals/Classification
RE: PC 8395 – Non-ACA Hospital Review Referrals
Organization Name & Address:  
EIN:  
MFT:  
Tax Period:  
Statute of Limitations:  
Principle Issue Code(s):  
Source Code: 96
Activity Code: 344
Tracking Number 1001 (Protection of Assets)
Project Definer Code 87 (last 2 digits ACA Review Phase & Wave)
Description of issue being referred:
 
 
 

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  ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
  • ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡

  • ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡

  • ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡

≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
≡ ≡ ≡