Page 1

Personal Care services to

help with activities of daily living CLIENT INTAKE FORM

PATIENT NAME REFERRED BY

Name Company:

ADDRESS CITY/STATE ZIP CODE

MAIN PHONE NUMBER OTHER PHONE NUMBER SOCIAL SEC NUMBER DATE OF BIRTH

N/A

HEALTH INSURANCE

Plan name: ID# Phone # Back of ID Card

WAIVER VETERAN

Again Independence Attendant Commcare Single Veteran Married Veteran

Consolidated Person Family Obra Alds N/A Surviving Spouse of a Veteran Not A Veteran

NAME OF PCP PHONE NUMBER ADDRESS

REFERRED LANGUAGE

English White Black/African American Asian

Spanish Multiracial Pacific Islander Hawaiian

Other Other Am. Indian/Alaska Native Unknown/Decline to Report

START OF CARE DATE SERVICES REQUIRED

Companion Personal Care Homemaking SN PT

MARITAL STATUS #PERSONS LIVING IN YOUR HOME TOTAL FAMILY HOUSEHOLD INCOME

EMERGENCY CONTACT
(Person responsible for providing day-to-day care for the patient)
N/A, I do not have a primary caregiver NAME RELATIONSHIP PHONE NUMBER
Same as emergency contact
N/A, I do not have a legal Guardian
Same as emergency contact

COMMENTS:
Client Name:
Page 2
Referral Information
Abuse/Neglect Adult Day Care Advocacy Animal Services Case Mgmt

Caregiver Services Property Tax Credit Dental Disabili es Food

Funeral Health Centers Hearing Home Health Homemaker

Home Repairs Home Del. Meals Housing Op ons Legal Services Mental Health Srvs.

Ombudsman Personal Care Senior Center Transporta on Veterans

Vision Other:

Nutritional Status

I have an illness or condi on that made me change the kind/amount of food ! eat.
I eat fewer than 2 meals per day.
I eat few fruits, vegetables, or milk products.
1 have 3 or more drinks of beer, liquor, or wine almost everyday.
I have tooth or mouth problems that make it hard for me to eat.
I don't always have enough money to buy the food I need.
I eat alone most of the me.
I take 3 or more different prescribed or over-the-counter drugs a day.
Without wan ng to, I have gained or lost 10 pounds in the past 6 months
I am not always physically able to shop, cook or feed myself.
Total score for each Yes response

(0-2: low risk: 3-5 moderate risk: 6 or more high risk)

Client
Date
Signature

Intake Worker
Date
Signature

Referral Source: Telephone Number:

Notes:
Client:: Page 3
FUNCTIONAL ASSESSMENT
Levels of Assistance:
0 Independent Completes the task independently 3-Minimum Assistance -Occasional assistance or supervision may be necessary
6- Moderate Assistance Assistance or supervision is always necessary
9= Maximum Assistance-Totally dependent on others
1 For each ac vity check the box indica ng the assistance needed.
2. If assistance is needed, indicate the source of help (be specific: spouse, family, friend, paid help, volunteer, professional)
3. in the comments sec on indicate the type of assistance provided and how o en it is provided. Also indicate if the client needs further help.

ACTIVITIES OF DAILY LIVING

Ind Min. Mod. Max. Primary Comments/Other Sources
Activity
0 Assist Assist Assist Source of Help
3 6 9
Eating
Bathing
Grooming
Dressing
Toilet Use
Mobility
Transferring
LexiCare Community Connection LLC.
Ind Min. Mod. Max. Primary Comments/Other Sources
Activity 0 Assist Assist Assist Source of Help
3 6 9
Laundry
Shopping
Light Housework
Heavy Housework
Telephone
Financial Management
Transportation
Meal Preparation
Medication
Management

Adaptive Equipment Has Has,Does

Not Use Needs Comments
Bathing Equip (bath bench, grab bars, etc)
Brace (leg, back) prosthesis
Cane, Crutches, Walker
Diabetic Supplies
Dentures
Railings
Hospital Bed
Medical Phone Alert
Toilet Equipment (e, raised commode)
Wheelchair (manual, power)
Other (specify)
Client Name:
Page 4

HOUSEHOLD CONVENIENCES

Client Client Observation: Does the client's home have health and safety issues relat-
Has Needs ed to any of the following?

Electricity General repair of home exterior

Gas, Propane Yard Condition

Heating System (type?) Sidewalk, exterior stairs

Air Conditioner (window or central) Exterior Lighting

Fan Odors (urine, garbage, peta)

Flush Toilets General Repair of Home Interior

Tub, Shower Interior Clutter

Piped water, hot/cold Interior Lighting

Stove, hotplate, oven, toaster oven Room Temperature

Can opener (electric or manual) Accessibility of Phone(s)

Microwave Food Storage

Accessibility of fire exits and
Blender
smoke detectors
Radio, television Bugs or rodents inside home

Refrigerator Accessibility of emergency phone

numbers
Telephone Unsafe Pathways

Washer Pets

Dryer No Problems

Comments:

PLACE OF RESIDENCE

What floor does the client live on? ______________ Is the bathroom on the same floor? Yes No
Number of steps to enter the home? Are steps a problem within the home? Yes No
If the client lives on other than the main floor:____________ Is there an elevator, li or stair li ? Yes No
Ask the Client the following: Do you have difficulty ge ng into your home? Yes No
Do you have difficulty ge ng into any room in your home? Yes No
Comments:

FALL RISK SCREENING (ask the client the following questions)

1. How many times have you fallen in the past year?__________

2. Are you worried you might have a fall? Not at all A little Somewhat Very
3. Do you limit activities now because of fall-related concerns? Occasionally Sometimes Never Often

If client has NOT fallen in the past year, skip questions 4 & 5 below.
4. Where have you fallen?
Getting in & out of bed Bathroom Outside the home
Between the bed & the bathroom Kitchen Other:
5. Can you say what makes you more likely to fall?
Feeling dizzy/lightheaded Getting up too quickly Walking in darkness
Certain Shoes Turns Walking on certain surfaces
Stairs Dim Lighting Other:
Client Name: Page 5

MEDICAL CONDITIONS
What are your medical problems? (use the following codes to answer)
1- had previously 2-under control Height:
3-has currently/being treated 4-has currently/ not being treated Weight:

Category Code Category Code Category Code Category

Cardiovascular Hearing/Vision Respiratory Skin

Ankle edema Deaf Asthma Pressure/other ulcer

By-pass surgery/ Angioplasty Hearing deficit COPD Rashes

Chest pain Hearing aid Cough (dry/productive) Shingles

Circulation problems Hearing Other Difficulty breathing Stasis dermatitis

Congestive heart failure Hearing No Problem Emphysema Other

Heart attack Blind Oxygen No problem

Hypertension Blurred Vision Bronchitis Genitourinary

Hypotension Cataracts Pneumonia Dialysis

Pacemaker Glaucoma Other Difficulty/frequent urination

Shortness of breath Macular Degenera on No problem Dribbling/Incontinence

Other Vision Other Frequent bladder infections

No problem Vision No Problem Nighttime urination/ Nocturia

Endocrine Infectious Disease Other

Diabetes AIDS No problem

Thyroid HIV positive

Other Hepatitis Neurological

No problem Tuberculcais Alzheimer's disease

Other Cerebral Palsy

Gastrointestinal No problem Other CVA/Stroke

Abdominal pain Reduced Physical Stamina Dementia

Colitis Musculoskeletal Dehydration Dizziness

Constipation Amputation of Allergies-food/ medicine Paralysis of

Diarrhea Arthritis-rheumatoid or Anemia Parkinson's Disease

osteo
Difficulty swallowing Back pain Autism Seizures/epilepsy

Diverticular disease Contractures Cancer Multiple Sclerosis (MS)

Frequent use of laxatives Developmental disabil Amyotrophic lateral sclero-sis

Fracture of ity
Gall bladder problems Joint replacement of Depression Other

Indigestion Polio/Post Palio Drug use/abuse No Problem

Irritable bowel syndrome Other Mental retardation PAIN

Ulcers No Problem Tobacco use Are you in pain now?

Other Obesity
If yes, rate your level of pain on a
scale of 1-10(1 indicates no pain,10
No Problem Chronic pain indicates the most intense level of
pain)
Other
PAIN LEVEL:
No Problem
Client Name: Page 6
MEDICAL PERSONNEL

Primary Doctor: Phone Number

Other In-home provider name: Phone Number o Short-term o Long-term

HEALTH CARE UTILIZATION

1. Overall, how would you rate your health at the present time? o Excellent o Good
o Excellent o Good o Fair o Poor o Do not know/Refused

2.During the past 12 months, were you admitted to the hospital for a stay that included at least
o Yes o No

If yes, indicate number of times admitted and ask the following question.

3. During the past 12 months, how many nights did you spend in the hospital?
Indicate # of nights o Do not know/Refused

4. During the past 12 months, how many trips did you make to the emergency room? (respondent as patient)
Indicate number of trips o None (skip to question 6) o Do not know/Refused (skip to question 6)

5. What was the main reason you went to the Emergency Room (if more than one visit, ask about most recent visit,
one response on-ly)?
o Medical Condition was Serious o No Other Source of Medical Care Was Available When Needed
o Referred by Health Professional/Caregiver o Do not know/Refused
o Other (Record Reason:)

6. How many primary care doctor visits (your main doctor, not including specialists) did you have during the past 12 months?
# of visits o None o Do not know/Refused

7. During the past 12 months, how many doctor visits did you have with specialist(s) (doctors other than your primary care doctor)?
Indicate number of visits o None o Do not know/Refused

8. During the past 12 months, did you receive a flu shot?

o Yes o No o Do not know/Refused

9. How long ago was your last doctor visit?

o During the past 60 days o During the past 3 to 12 months o Between 1 and 2 years ago
o 2 to 4 years ago o More than 4 years ago o Never seen a doctor o Do not know/Refused

10. During the past year, were you ever unable to see a doctor when you needed to?
o Yes o No (skip to question 12) o Do not know/Refused (skip to question 12)

11. If you were unable to see a doctor when you needed to, was it because of (check all yes responses):
o Cost too much o Lack of transportation o Conid not get appointment
o Doctor would not accept Medicaid o Limited hours of service o Other reason o Do not know/Refused

12. During the past 12 months, were you admitted to a nursing home? (all levels of care)
o Yes o No
If yes, indicate number of admissions and indicate # of nights o Do not know/Refused

13. Overall, how satisfied are you with the quality of the medical care you received during the past year?
o Very satisfied o Somewhat satisfied o Somewhat dissatisfied
o Very dissatisfied o Do not know/Refused

14. Are finances a factor in obtaining adequate health/medical care? o Yes o No

15. Is transportation a factor in obtaining adequate health/medical care? o Yes o No

 Page 7
APPLICATION FOR SERVICES AGREEMENT

Application For services Agreement

L enter into agreement with Lexicare
Community Connection LLC.

Supportive Home Care LLC (RSHC) to receive personal assistance services for the following
client: The following activities may or may not
be included in these services: food preparation, cooking, washing, shaving, dressing, toileting,
regular hair and skin care, ambulating, transferring, exercise, and assistance with self-
administered medications. Services are restricted not just to the tasks mentioned, but also to the
extent of an unlicensed person's skill. I recognize that if the client receiving services' condition
changes and skilled treatment is needed, RSHC would be unable to provide it. I am aware that I
have the right to refuse medical treatment

I understand that services will be provided by staff who will visit the client's home. I recognize
that, if the client so desires, a plan of treatment will be developed with the client's and/or family's
input. I recognize that it is my right and duty to participate in the care plan, and that I will be
given a copy of my medical records. This strategy, I understand, will be revised and supervised
at least once every by a supervisor from the department, either in person or
by telecommunications. I can reach the supervisor by calling the department, and I can reach the
agency office at (272)219-0900 if I have any questions before or after business hours.

I consent to pay $ per for the services provided to the client by

Lexicare Community Connection LLC. Supportive Home Care LLC. The start date of services is
set for
Frequency of services is: My payment method is
Pre-pay, Direct Debit State billing Private Pay/invoice
I recognize that I am liable for payment if a third-party refuse to pay for any reason,
including insurance refusal or denial from any other payment source. I recognize that a deposit
might be needed due to a fluctuating payment schedule or the involvement of a third party in the
payment process. In the event that a deposit is required, I agree to pay the deposit amount equal
to one month's service based on hours scheduled and payment must be made for services to
continue. I agree to pay only the appropriate agency representative and to make no charge,
bonus, or reimbursement to the caregiver for their services. I understand that payment is due
upon receipt, and that if payment is not received within six days of the invoice date, a late fee
may be paid. I will pay for all service hours that are not contested if there is a difference on hours
worked. No one can claim power of attorney or guardianship over a client who uses the agency's
services as a result of their association with the agency. The client would not be required to
endorse checks to the department.

I give my permission for the agency to disclose medical details to my doctor, a facility of my
choosing, a payer source, or accrediting/regulatory/organizations that provide consultancy
services, as required. When I move to another health care facility, I approve the release of my
Plan of Treatment and Discharge Summary upon my transfer to another healthcare facility.
 Page 8

APPLICATION FOR SERVICES AGREEMENT

I was given a verbal summary as well as a copy of the Elder Abuse, Exploitation, Neglect, and/or
Theft Policy, Client Rights and Responsibilities, Advanced Directives, Medical and Special
Waste Disposal, and the agency's policy on Abuse, Exploitation, Neglect, and/or Theft. I
understand that if I believe there has been violence, neglect, fraud, or exploitation, I should
report it to the Monroe County Area Agency on Aging, 724 B Phillips Street, Stroudsburg PA
18360. Toll free hotline at 1-800-498-0330 as well as the Department of Health's complain
Hotline at (1800) 254-5164. The line is open to you 24 hours a day and 7 days a week. I
understand that I may also contact my local AAA Ombudsman of Monroe County at 1-570-420- 3735.
I understand that I may also file a complaint with the Director or president of Lexicare Community
Connection LLC.Supportive Home Care LLC agency office at (272-219-0900). The agency will
respond to your
complaint within 10 days and your concerns will be resolved within 30 days.

(yes) (No) Has a Durable Will (Yes) (No) Has an out of Hospital DNR
(Yes) (No) Has a Living Will. (Yes) (No) Has a Directive to Physician/Living Will
Name of Durable Power of Attorney Phone Number

For the purpose of care management, the client gives permission to contact their primary
care physician and other service providers.

Time sheets are requested to be sent with invoices by a third party.

I understand that prior to employment, the agency does not require its workers to undergo a drug
test. I accept that I would not hire or offer to hire a caregiver assigned to client's care to work
privately and/or directly for client or any individuals affiliated with client at any time while
obtaining services from RSHC or within six months after services have been terminated. I
recognize that I would not obligate any agency caregiver to perform activities that are beyond
their ability or the scope of the agency's services. If RSHC has to end this arrangement, I will be
given at least ten days' notice, unless there are circumstances that require immediate transfer or
discharge, as specified in the Client Handbook. I recognize that if a client or family member is
psychologically or physically abusive, services should be discontinued. I recognize that if a
client or family sends away more than three caregivers in a row without verifiable evidence that
such caregivers were unable to provide treatment, the agency will be unable to provide services.

Client or Responsible Party Social Security Number Date

Agency Representative Date

 LexiCare Community Connection LLC.
Care Plan Page 9

Name: Phone: D.O.B HGT: WGT:

Address:
Emergency Contact: Relationship:
Phone:
Emergency Status: (911) (DNR) (MD) Care Manager:
Phone:
Home Health Hospice:
Drug/Misc. Allergies: Smoker: (Yes) (No) Pets: (Yes) (No)
Live Alone (Yes) (No) Hard of Hearing (yes) (No) Poor Vision (yes) (No) Unable to Speak (Yes) (No). Unclear Speech (Yes) (No)
Forgetful: (Yes) (No) Confused: (yes) (No)

DOH REQUIREMENT

PAYMENT Method: Act 150/UPMC( ) AmeriHealth Waiver ( ) PA Health and Wellness waiver ( ) Medicaid ( ) OBRA Waiver ( )

PDA Waiver () Private Funding ( ) COMM care Waiver ( ) Independence waiver ( ) Name of another Waiver

Frequency of care: Sun: Thursday:

Mon: Fir:

Tues: Sat:

Wed: As requested by consumer (varies

Direct Support Worker Assigned:

SIGNIFICANT MEDICAL HISTORY

Outcomes & Goals

Outcomes/Goals Needed Detail

Bath/Shower
Bed Bath/Sponge Bath
Toileting
Incontinent Care
Grooming/Hair Care
Oral care
Shaving
Skin Care/Changes
Dressing/Undressing
Transfer/Positioning
Ambulation
Use Assistive Devices
 Page 10

Dietary Guidance
Outcomes/Goals Needed Detail
Medication Reminders
Assist With Feeding
Meal Preparation
Dust/Mop/Sweep/Vacuum
Kitchen Chores/Dishes
Bathroom Cleaning
Trash Removal
Change Bed linens
Medication reminder
Laundry/Ironing
Safety/Oversight/ Supervision
Prepare For Bed
Transportation/Brands/Shopping
Outdoor Recreation
Money exchange
Assist With Exercise
Socialization/Peer Interaction
Safety Skills
Independent Living Skills
Personal Hygiene Skills
Behavior Intervention
Respite
Companionship
Home& Community Habilitation
Other

Client signature: Date:

Agency Representative signature: Date:

LexiCare Community Connection LLC.
CLIENT'S HANDBOOK AND COMPLAINT PROCEDURE Signature page.

By signing this form, all clients who receive services from Lexicare Community Page 11
Connection LLC. Supportive
Home care LLC are attesting that they have received the client's handbook which
describes the policies and services offered by the agency and also the Client
Complaint Procedure handbook.

Client Signature: Date:

Client Representative Signature: Date:

Agency/Agency Representative Signature: Date:

 Page 12

TRANSPORTATION LexiCare ACKNOWLEDGE

LexiCare Community Connection LLC. allows employees to drive a client's vehicle for incidental
transportation as part of our operation. If a client does not have access to a vehicle or has no
other means of transportation, they may request that an RSHC employee transport them in one of
their vehicles. On the day of hiring, we check to see if the employee has a valid driver's license
and make a formal submission for a vehicle record.

We request and arrange a monthly Motor Vehicle Record Check of the providing caregiver from
our third-party background check company as part of our transportation program, and we verify
insurance coverage on individual employees' vehicles. Please initial the required field below and
sign if transportation is needed as part of our service.

Client as a passenger in an employee vehicle:

I can include the use of an RSHC employee's vehicle for incidental transportation. I
completely understand and agree to keep the provider, Lexicare Community Connection LLC.
Supportive Home Care LLC, its
staff, and principals harmless and indemnify them from any liability in the event that I (client)
am injured while riding in the employee's vehicle. It is our policy that the client or their family
members cannot drive our employees in any vehicle whatsoever, so therefore the employee must
be the driver of that vehicle for safety reasons. If a LexiCare Community Connection LLC. team
member's vehicle is used for commuting or to run client errands, we reserve the right to charge
mileage at the $ rate.

Employee as a driver of a client's vehicle:

understand andFor incidental

support that
transportation,
I have sufficient
I cancar
request
insurance
that an
coverage
RSHC that
employee
includes
drive
third-party
my car. I
drivers. In the event of an accident-causing damage to my vehicle or injury to myself, I
completely indemnify and keep harmless the provider, LexiCare Community Connection LLC., its
staff, and principals and other occupants in said vehicle.

Client or Legal Representative Date

LexiCare Community Connection LLC. Representative Date

 Page 13

LexiCare Community Connection LLC.

CLIENT'S VIAL OF LIFE LIST
Client Name:

Address:

D.O.B:

Does this client have a DNR order?

Known Allergies:

Doctor's name:

Doctor's Address?

Which pharmacy does this client use?

Address?

Phone:

Power of Attorney:

Client's Diagnosis:

Is client a hospice patient?

Does Client have an advanced Directive?

Name of Home care agency providing services:

Phone Number:

Medication Name Frequency PRN's Discontinued

 Page 14

Medication Name Frequency PRN's Discontinued

 Page 15

DIRECT CARE WORKER EXPECTATIONS

Training and Competency Policy/Testing, Timeframes and Frequency in Accordance with PA Home
Care Regulation 611.55

Our direct care workers are properly trained and should appear neatly groomed and dressed in scrubs
when visiting your home to provide care. Direct Care Workers will wear an identification badge for your
protection. The identification will identify their name, picture and their affiliation withLexiCare Community
Connection LLC.If a direct care worker is not wearing their identification while in your home
please ask them to display it as well as contact our office immediately. Direct Care Workers are bonded
and insured for your protection. Each applicant is carefully screened by means of a background check,
medical checks and competency exams and trainings in order to be considered eligible for employment.
A list of the screenings is itemized for new hires:

Reference Checking (minimum of 2 satisfactory results) Child Abuse Clearances FBI Background checks
State background checks (Only for individuals who have not lived in Pennsylvania for 2 or more
consecutive years. (Only individuals who will be providing care to a minor (less than 18 years old)
Megan's Law Background checks, Drug Testing, Motor Vehicle Background checks, Tuberculosis
screenings (performed both initially and annually). Professional License verification as needed, Home
Care Training as needed, Competency Testing for skill and knowledge (performed initially and annually).
The training is hosted by Lexicare Community Connection LLC. Supportive Home Care Nurse or
competent office Administrator)Competency is tested in the following areas: Recognizing and Reporting
Abuse or Neglect, Hair, Skin, and
Mouth Care, Assistance with Self-Administered Medication. Dealing with Difficult Behaviors, Bathing,
Shaving, Grooming, and Dressing. Assistance with ambulation and Transferring, Toileting, Meal
Preparation and feeding. Documentation, Universal Precautions, Recognizing consumer changes, Basic
infection Control, Consumer control and independent Living Philosophy. Confidentiality Instrumental
Activities of Daily Living Philosophy.

Trainings are offered through direct observations, testing and training, consumer feedback as well as
online learning opportunities. Competency is reviewed once per year after the initial competency is
established and more frequently when discipline or other sanction is imposed because of quality of
care infraction.
 Page 16

Home Health Agency

Outcome and Assessment Information Set(OASIS)
STATEMENT OF PATIENT PRIVACY RIGHTS
As a home health patient, you have the privacy rights listed below.

You have the right to know why we need to ask you questions.
We are required by law to collect health information to make sure:
1) you get quality health care, and
2) payment for Medicare and Medicaid patients is correct.

You have the right to have your personal health care information
kept confidential.

You may be asked to tell us information about yourself so that

we will know which home health services will be best for you.
We keep anything we learn about you confidential.
This means, only those who are legally authorized to know, or who
have a medical need to know, will see your personal health information.

You have the right to refuse to answer questions.

We may need your help in collecting your health information.

If you choose not to answer, we will fill in the information as best we can.
You do not have to answer every question to get services.

You have the right to look at your personal health information.

We know how important it is that the information we collect about you is correct. If
you think we made a mistake, ask us to correct it.
If you are not satisfied with our response, you can ask the Centers for Medicare &
Medicaid Services, the federal Medicare and Medicaid agency, to correct your
information.

You can ask the Centers for Medicare & Medicaid Services to see, review, copy, or correct your personal health
information which that Federal agency maintains in its HHA OASIS System of Records. See the back of this
Notice for CONTACT INFORMATION. If you want a more detailed description of your privacy rights, see the
back of this Notice: PRIVACY ACT STATEMENT-HEALTH CARE RECORDS.

This is a Medicare & Medicaid Approved Notice.

 LexiCare Page 17

Community Connection LLC.

Consumer Notice of Direct Care Worker Status
This form is to be completed by every consumer utilizing
the services of a Home care Agency or Home Care Registry

Initial Both Sections Below:

I, understand that:

PRINT NAME

Initials: The direct care worker who will be providing services in my home is an employee
of LexiCare Community Connection LLC. RSHC is responsible for withholding State and Federal
Income tax, Federal Unemployment tax, Social Security taxes and Medicare taxes on behalf of the
direct care worker. RSHC is also responsible for paying workers' compensation insurance to cover
the direct care worker in the event of an accident or injury on the job.

OR

N/A The direct care worker who will be providing services in my home is not an employee of N/A

and therefore, may be considered my employee. Since the direct care worker maybe my employee.
I may be responsible for withholding and reporting State and Federal Income tax. Federal
Unemployment tax, Social Security taxes and Medicare taxes on behalf of the direct care worker.
I also understand that the direct care worker is not covered by workers' compensation insurance.

Initials I have been informed that LexiCare Community Connection LLC.

X_Maintains

does not maintain

general and professional liability insurance covering the direct care worker.

If LexiCare Community Connection LLC. does not maintain general and professional liability
insurance, and the direct care worker is not covered under workers' compensation, I have been
advised to check my homeowner's or renter's insurance to determine if it covers any injury or
accident involving the direct care worker while working in my home.

CONSUMER SIGNATURE DATE

AGENCY REPRESENTATIVE SIGNATURE DATE