Interim Payment Agreement

User Roles:

AM

AR

D

Payment Authorization

Amount of Payment Request: $xxx.xx

Date of Payment Request: mm, dd, yyyy

Payment is contingent on compliance with the Plan Sponsor agreement and with Retiree Drug Subsidy (RDS) program requirements, including the applicable laws and regulations.

Authorized Payment Requestor, on behalf of the Plan Sponsor, agrees that CMS is authorized to initiate payment in accordance with the provisions of 42 CFR 423 Subpart R and applicable provisions of 45 CFR 30 Subpart B, to the account at the financial institution (hereinafter the "Depository") indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor application, and Plan Sponsor will promptly notify CMS of any changes in its Depository information and submit an updated EFT Authorization.

I, the undersigned Authorized Payment Requestor, on behalf of the Plan Sponsor, declare that I have examined this Interim Payment Request and certify that the information contained in this Interim Payment Request is true, accurate and complete to the best of my knowledge and belief. I understand that, because payment of a subsidy will be made from Federal funds, any false statements, documents, or concealment of a material fact is subject to prosecution under any applicable Federal and/or State law.