g%FDF-1.2
%ΥΧΩΟ
1 0 obj
<< 
/FDF << /Fields 2 0 R >> 
>> 
endobj
2 0 obj
[ 
<< /T (pdfBasedOnFDF)/V (True)>> << /T (pdfTemplateStyle)/V (EOI)>> 
<< /T (pdfName)/V (FreedomExpressions.pdf)>> << /T (pdfType)/V (BATCH EOI)>> 
<< /T (eeGroupNumber)/V (123456)>> << /T (eeAccountNumber)/V (4)>> 
<< /T (eeLocationName)/V (004)>> << /T (eeEmployerName)/V (FREEDOM EXPRESSIONS, INC.)>> 
<< /T (eSignatureApproved)/V (Y)>> << /T (eeSSN)/V (939129429)>> << /T (eeLastName)/V (Mccormick)>> 
<< /T (eeFirstName)/V (Steve)>> << /T (eeMiddleName)/V (L.)>> << /T (eeFullDOB)/V (11/12/1942)>> 
<< /T (eeSexchk)/V (Male)>> << /T (eeSexCode)/V (Male)>> << /T (eeFullDOH)/V (05/07/1996)>> 
<< /T (eeAnnualSalary)/V (24,086.40)>> << /T (submitReasonCode)/V (Late Entrant)>> 
<< /T (submitReason)/V (Late Entrant)>> << /T (eeHomeAddress)/V (4960 Bark Way)>> 
<< /T (eeCity)/V (Colorado Springs)>> << /T (eeState)/V (CO)>> << /T (zip1)/V (80917)>> 
<< /T (eeAreaCode)/V (555)>> << /T (eePhone)/V (2342340)>> 
<< /T (eeHeightFt)/V (5)>> << /T (eeHeightIn)/V (7)>> << /T (eeWeight)/V (170)>> 
<< /T (eePhysicianInfo)/V (ExpressCare Plus 3421 Academy Cir. S. Colorado Springs, CO)>> 
<< /T (signedDate)/V (11/24/2004)>> << /T (eeAuthorizeSignature)/V (Electronically signed via User ID and PIN)>> 
<< /T (eeSignature)/V (Electronically signed via User ID and PIN)>> 
<< /T (aqi1chk)/V (No)>> << /T (healthQ1Response)/V (No)>> << /T (aqi2chk)/V (No)>> 
<< /T (healthQ2Response)/V (No)>> << /T (aqi3chk)/V (No)>> << /T (healthQ3Response)/V (No)>> 
<< /T (aqi4chk)/V (No)>> << /T (healthQ4Response)/V (No)>> << /T (aqi5chk)/V (No)>> 
<< /T (healthQ5Response)/V (No)>> << /T (aqi6chk)/V (No)>> << /T (healthQ6Response)/V (No)>> 
<< /T (aqi7chk)/V (No)>> << /T (healthQ7Response)/V (No)>> << /T (aqi8chk)/V (No)>> 
<< /T (healthQ8Response)/V (No)>> << /T (aqi9chk)/V (No)>> << /T (healthQ9Response)/V (No)>> 
<< /T (aqi10chk)/V (No)>> << /T (healthQ10Response)/V (No)>> << /T (eeCurrAmt)/V (0)>> 
<< /T (eeTotalAmt)/V (0)>> << /T (eeAmtUW)/V (0)>> << /T (eeSuppchk)/V (Yes)>> 
<< /T (eeSuppCurrAmt)/V (0)>> << /T (eeSuppTotalAmt)/V (20000)>> 
<< /T (eeSuppAmtUW)/V (20000)>> << /T (spCurrAmt)/V (0)>> << /T (spTotalAmt)/V (0)>> 
<< /T (spAmtUW)/V (0)>> << /T (spSuppCurrAmt)/V (0)>> << /T (spSuppTotalAmt)/V (0)>> 
<< /T (spSuppAmtUW)/V (0)>> << /T (chCurrAmt)/V (0)>> << /T (chTotalAmt)/V (0)>> 
<< /T (chAmtUW)/V (0)>> 
]
endobj
trailer
<<
/Root 1 0 R 

>>
%%EOF