Set-up fee___________dollar amount of fee
Monthly service fee_____dollar amount of fee or method of determining amount
Settlement fee_______dollar amount of fee or method of determining amount
Goods and services in addition to those provided in connection with a plan:
_________________
(item) dollar amount or method of determining amount
_________________
(item) dollar amount or method of determining amount.
IMPORTANT INFORMATION FOR YOU TO CONSIDER
___________________
Name and business address of provider
IMPORTANT INFORMATION FOR YOU TO CONSIDER
___________________
Name and business address of provider
IMPORTANT INFORMATION FOR YOU TO CONSIDER
___________________
Name and business address of provider
C.R.S. § 5-19-217
This section is similar to former § 12-14.5-217 as it existed prior to 2017.