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 of fee or method of determining amount
______________
(item) Dollar amount of fee 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
T.C.A. § 47-18-5517