DISCLOSURES & ADDITIONAL COSTS:

Labor Code §§ 4628 and 5703:

The History, record review examination, drafting and composition of conclusions of this report, herein “evaluation,” were performed exclusively by Dr. Douglas M. Gillard, DC, IDE, QME, which occurred at the following location:

And occurred on the following date:

The evaluation performed and time spent performing said evaluation were in compliance with “Labor Code §139.2(j) or Labor Code §5307.6.” No other persons performed “services in connection with the report” other than “its clerical preparation.”

“reasonable costs of clerical expense necessary to producing the report” include the following: $18.00 for packing and shipping.

“reasonable overhead expense” includes the following: $25.00 for materials and postage.

Pursuant to Labor Code §4628(j), "I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true." More the one third of my “total practice time” is annually devoted to the “medical treatment” of patients.

Per Labor Code §5703(a)(2), there has not been a violation of Section 139.3 and the contents of the report are true and correct to the best knowledge of Dr. Gillard’s knowledge. The foregoing statement is made under penalty of perjury.

This report was signed in the County of Santa Clara on _________________________.

Douglas M. Gillard, DC, IDE, QME