<style type="text/css"> .myTable,.myTable td { page-break-after:always; font-family:宋体;font-size:9pt; padding-right:0.5pt; padding-left:0.5pt; padding-top:0.5pt; padding-bottom:0.5pt; border-style:solid;border-width:1px 0 0 1px; } </style> <table cellspacing="0" cellpadding="0" border="0" class="myTable" style="border-width:0;width:555pt"> <tbody><tr style="height:0px"><td style="border-width:0;width:28pt"></td> <td style="border-width:0;width:95pt"></td> <td style="border-width:0;width:87pt"></td> <td style="border-width:0;width:103pt"></td> <td style="border-width:0;width:84pt"></td> <td style="border-width:0;width:76pt"></td> <td style="border-width:0;width:75pt"></td> </tr><tr style="height:55pt"> <td align="center" colspan="7" style="border-width:0"><font style="font-size:22pt;font-weight:bold;">住宅专项维修资金实际使用分摊表</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">一、小区名称</font></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="7"><font style="font-size:14pt;">&nbsp;&nbsp;&nbsp;&nbsp;圣园（圣芭芭拉）</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">二、维修项目概况</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:18pt"> <td values="" style="border-width:0" bindtype="0" rowspan="11" colspan="7" datasource="" type="textarea' styles='line-height:37px"><font style="font-size:14pt;">　　1、圣园（圣芭芭拉）圣园（圣芭芭拉）171171#电梯，已维修完毕，结算金额：5,<br>000.00元，审价费用：250,合计：5,250.00； <br>　　2、圣园（圣芭芭拉）圣园（圣芭芭拉）181181#电梯，已维修完毕，结算金额：1,<br>800.00元，审价费用：125,合计：1,925.00； <br>　　3、圣园（圣芭芭拉）圣园168168168#电梯，已维修完毕，结算金额：1,800.00元，<br>审价费用：125,合计：1,925.00； <br>　　4、圣园（圣芭芭拉）圣园（圣芭芭拉）178178#电梯，已维修完毕，结算金额：1,<br>800.00元，审价费用：125,合计：1,925.00； <br>　　5、圣园（圣芭芭拉）圣园（圣芭芭拉）236236#电梯，已维修完毕，结算金额：1,<br>800.00元，审价费用：125,合计：1,925.00。 <br>&nbsp;&nbsp;总合计：12,950.00元</font></td> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:18pt"> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">三、施工日期</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:14pt"> <td type="textarea' styles='line-height:37px" colspan="7" datasource="" values="" style="border-width:0" bindtype="0"><font style="font-size:14pt;">　　开始日期：2020-11-01；结束日期：2020-12-01。</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">四、施工单位</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:14pt"> <td type="textarea' styles='line-height:37px" colspan="7" datasource="" values="" style="border-width:0" bindtype="0"><font style="font-size:14pt;">　　1、无锡广奥电梯有限公司</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">五、验收结论</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:42pt"> <td type="textarea' styles='line-height:37px" colspan="7" datasource="" values="" style="border-width:0" bindtype="0"><font style="font-size:14pt;">　　合格 <br>&nbsp;&nbsp;验收时间：2020年12月02日</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">六、参与验收人员</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:14pt"> <td type="textarea' styles='line-height:37px" colspan="7" datasource="" values="" style="border-width:0" bindtype="0"><font style="font-size:14pt;">　　杭春华、张海霞、无锡风水隆物业管理有限公司、无锡广奥电梯有限公司</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">七、公示时间</font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> <td style="border-width:0"><font style="font-size:14pt;"></font></td> </tr> <tr style="height:14pt"> <td type="textarea' styles='line-height:37px" colspan="7" datasource="" values="" style="border-width:0" bindtype="0"><font style="font-size:14pt;">　　2021年05月21日至2021年05月21日。</font></td> </tr> <tr style="height:14pt"> <td style="border-width:0" colspan="2"><font style="font-size:14pt;font-weight:bold;">八、分摊清册</font></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> </tr> <tr style="height:14pt"> <td align="center">序号</td> <td align="center">房屋地址</td> <td align="center">房屋面积(㎡)</td> <td align="center">结算应拨金额(元)</td> <td align="center">自筹金额(元)</td> <td align="center">分摊金额(元)</td> <td align="center" style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">1</td> <td align="center">圣园（圣芭芭拉）168单元101室</td> <td align="center">232.5900</td> <td align="center">258.10</td> <td align="center">0</td> <td align="center">258.10</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">2</td> <td align="center">圣园（圣芭芭拉）168单元102室</td> <td align="center">228.1800</td> <td align="center">253.21</td> <td align="center">0</td> <td align="center">253.21</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">3</td> <td align="center">圣园（圣芭芭拉）168单元201室</td> <td align="center">156.9100</td> <td align="center">174.12</td> <td align="center">0</td> <td align="center">174.12</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">4</td> <td align="center">圣园（圣芭芭拉）168单元202室</td> <td align="center">156.9100</td> <td align="center">174.11</td> <td align="center">0</td> <td align="center">174.11</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">5</td> <td align="center">圣园（圣芭芭拉）168单元301室</td> <td align="center">139.9800</td> <td align="center">155.33</td> <td align="center">0</td> <td align="center">155.33</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">6</td> <td align="center">圣园（圣芭芭拉）168单元302室</td> <td align="center">139.9800</td> <td align="center">155.33</td> <td align="center">0</td> <td align="center">155.33</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">7</td> <td align="center">圣园（圣芭芭拉）168单元401室</td> <td align="center">136.3000</td> <td align="center">151.24</td> <td align="center">0</td> <td align="center">151.24</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">8</td> <td align="center">圣园（圣芭芭拉）168单元402室</td> <td align="center">136.3000</td> <td align="center">151.24</td> <td align="center">0</td> <td align="center">151.24</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">9</td> <td align="center">圣园（圣芭芭拉）168单元501室</td> <td align="center">203.8000</td> <td align="center">226.16</td> <td align="center">0</td> <td align="center">226.16</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">10</td> <td align="center">圣园（圣芭芭拉）168单元502室</td> <td align="center">203.8000</td> <td align="center">226.16</td> <td align="center">0</td> <td align="center">226.16</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">11</td> <td align="center">圣园（圣芭芭拉）171单元101室</td> <td align="center">233.0800</td> <td align="center">690.94</td> <td align="center">0</td> <td align="center">690.94</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">12</td> <td align="center">圣园（圣芭芭拉）171单元102室</td> <td align="center">233.0800</td> <td align="center">690.94</td> <td align="center">0</td> <td align="center">690.94</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center" style="border-width:1px 0 1px 1px">13</td> <td align="center" style="border-width:1px 0 1px 1px">圣园（圣芭芭拉）171单元201室</td> <td align="center" style="border-width:1px 0 1px 1px">161.1400</td> <td align="center" style="border-width:1px 0 1px 1px">477.68</td> <td align="center" style="border-width:1px 0 1px 1px">0</td> <td align="center" style="border-width:1px 0 1px 1px">477.68</td> <td style="border-width:0 0 0 1px"></td> </tr> </tbody></table> <table cellspacing="0" cellpadding="0" border="0" class="myTable" style="border-width:0;width:555pt"> <tbody><tr style="height:0px"><td style="border-width:0;width:28pt"></td> <td style="border-width:0;width:95pt"></td> <td style="border-width:0;width:87pt"></td> <td style="border-width:0;width:103pt"></td> <td style="border-width:0;width:84pt"></td> <td style="border-width:0;width:76pt"></td> <td style="border-width:0;width:75pt"></td> </tr><tr style="height:14pt"> <td align="center">14</td> <td align="center">圣园（圣芭芭拉）171单元202室</td> <td align="center">161.1400</td> <td align="center">477.68</td> <td align="center">0</td> <td align="center">477.68</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">15</td> <td align="center">圣园（圣芭芭拉）171单元301室</td> <td align="center">144.2900</td> <td align="center">427.72</td> <td align="center">0</td> <td align="center">427.72</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">16</td> <td align="center">圣园（圣芭芭拉）171单元302室</td> <td align="center">144.2900</td> <td align="center">427.72</td> <td align="center">0</td> <td align="center">427.72</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">17</td> <td align="center">圣园（圣芭芭拉）171单元401室</td> <td align="center">140.4800</td> <td align="center">416.43</td> <td align="center">0</td> <td align="center">416.43</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">18</td> <td align="center">圣园（圣芭芭拉）171单元402室</td> <td align="center">140.4800</td> <td align="center">416.43</td> <td align="center">0</td> <td align="center">416.43</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">19</td> <td align="center">圣园（圣芭芭拉）171单元501室</td> <td align="center">206.2600</td> <td align="center">611.43</td> <td align="center">0</td> <td align="center">611.43</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">20</td> <td align="center">圣园（圣芭芭拉）171单元502室</td> <td align="center">206.8000</td> <td align="center">613.03</td> <td align="center">0</td> <td align="center">613.03</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">21</td> <td align="center">圣园（圣芭芭拉）178单元101室</td> <td align="center">232.6200</td> <td align="center">258.98</td> <td align="center">0</td> <td align="center">258.98</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">22</td> <td align="center">圣园（圣芭芭拉）178单元102室</td> <td align="center">232.6200</td> <td align="center">258.98</td> <td align="center">0</td> <td align="center">258.98</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">23</td> <td align="center">圣园（圣芭芭拉）178单元201室</td> <td align="center">155.7300</td> <td align="center">173.38</td> <td align="center">0</td> <td align="center">173.38</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">24</td> <td align="center">圣园（圣芭芭拉）178单元202室</td> <td align="center">155.7300</td> <td align="center">173.38</td> <td align="center">0</td> <td align="center">173.38</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">25</td> <td align="center">圣园（圣芭芭拉）178单元301室</td> <td align="center">138.9200</td> <td align="center">154.65</td> <td align="center">0</td> <td align="center">154.65</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">26</td> <td align="center">圣园（圣芭芭拉）178单元302室</td> <td align="center">138.9200</td> <td align="center">154.65</td> <td align="center">0</td> <td align="center">154.65</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">27</td> <td align="center">圣园（圣芭芭拉）178单元401室</td> <td align="center">135.2500</td> <td align="center">150.57</td> <td align="center">0</td> <td align="center">150.57</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">28</td> <td align="center">圣园（圣芭芭拉）178单元402室</td> <td align="center">135.2500</td> <td align="center">150.57</td> <td align="center">0</td> <td align="center">150.57</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">29</td> <td align="center">圣园（圣芭芭拉）178单元501室</td> <td align="center">202.3000</td> <td align="center">225.22</td> <td align="center">0</td> <td align="center">225.22</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">30</td> <td align="center">圣园（圣芭芭拉）178单元502室</td> <td align="center">201.7600</td> <td align="center">224.62</td> <td align="center">0</td> <td align="center">224.62</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">31</td> <td align="center">圣园（圣芭芭拉）181单元101室</td> <td align="center">227.5900</td> <td align="center">253.42</td> <td align="center">0</td> <td align="center">253.42</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">32</td> <td align="center">圣园（圣芭芭拉）181单元102室</td> <td align="center">232.0000</td> <td align="center">258.33</td> <td align="center">0</td> <td align="center">258.33</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">33</td> <td align="center">圣园（圣芭芭拉）181单元201室</td> <td align="center">156.3900</td> <td align="center">174.13</td> <td align="center">0</td> <td align="center">174.13</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">34</td> <td align="center">圣园（圣芭芭拉）181单元202室</td> <td align="center">156.3900</td> <td align="center">174.13</td> <td align="center">0</td> <td align="center">174.13</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">35</td> <td align="center">圣园（圣芭芭拉）181单元301室</td> <td align="center">139.5100</td> <td align="center">155.34</td> <td align="center">0</td> <td align="center">155.34</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">36</td> <td align="center">圣园（圣芭芭拉）181单元302室</td> <td align="center">139.5100</td> <td align="center">155.34</td> <td align="center">0</td> <td align="center">155.34</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">37</td> <td align="center">圣园（圣芭芭拉）181单元401室</td> <td align="center">135.8500</td> <td align="center">151.26</td> <td align="center">0</td> <td align="center">151.26</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">38</td> <td align="center">圣园（圣芭芭拉）181单元402室</td> <td align="center">135.8500</td> <td align="center">151.26</td> <td align="center">0</td> <td align="center">151.26</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">39</td> <td align="center">圣园（圣芭芭拉）181单元501室</td> <td align="center">202.6000</td> <td align="center">225.60</td> <td align="center">0</td> <td align="center">225.60</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">40</td> <td align="center">圣园（圣芭芭拉）181单元502室</td> <td align="center">203.1300</td> <td align="center">226.19</td> <td align="center">0</td> <td align="center">226.19</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">41</td> <td align="center">圣园（圣芭芭拉）236单元101室</td> <td align="center">104.2200</td> <td align="center">183.18</td> <td align="center">0</td> <td align="center">183.18</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">42</td> <td align="center">圣园（圣芭芭拉）236单元102室</td> <td align="center">64.2900</td> <td align="center">112.99</td> <td align="center">0</td> <td align="center">112.99</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">43</td> <td align="center">圣园（圣芭芭拉）236单元201室</td> <td align="center">93.5800</td> <td align="center">164.47</td> <td align="center">0</td> <td align="center">164.47</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">44</td> <td align="center">圣园（圣芭芭拉）236单元202室</td> <td align="center">91.7700</td> <td align="center">161.29</td> <td align="center">0</td> <td align="center">161.29</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">45</td> <td align="center">圣园（圣芭芭拉）236单元301室</td> <td align="center">93.5800</td> <td align="center">164.48</td> <td align="center">0</td> <td align="center">164.48</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">46</td> <td align="center">圣园（圣芭芭拉）236单元302室</td> <td align="center">91.7700</td> <td align="center">161.29</td> <td align="center">0</td> <td align="center">161.29</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">47</td> <td align="center">圣园（圣芭芭拉）236单元401室</td> <td align="center">93.5800</td> <td align="center">164.47</td> <td align="center">0</td> <td align="center">164.47</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">48</td> <td align="center">圣园（圣芭芭拉）236单元402室</td> <td align="center">91.7700</td> <td align="center">161.29</td> <td align="center">0</td> <td align="center">161.29</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">49</td> <td align="center">圣园（圣芭芭拉）236单元501室</td> <td align="center">93.5800</td> <td align="center">164.48</td> <td align="center">0</td> <td align="center">164.48</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">50</td> <td align="center">圣园（圣芭芭拉）236单元502室</td> <td align="center">91.7700</td> <td align="center">161.29</td> <td align="center">0</td> <td align="center">161.29</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">51</td> <td align="center">圣园（圣芭芭拉）236单元601室</td> <td align="center">93.5800</td> <td align="center">164.48</td> <td align="center">0</td> <td align="center">164.48</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">52</td> <td align="center">圣园（圣芭芭拉）236单元602室</td> <td align="center">91.7700</td> <td align="center">161.29</td> <td align="center">0</td> <td align="center">161.29</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td style="border-width:1px 0 0 0"></td> <td style="border-width:1px 0 0 0"></td> <td style="border-width:1px 0 0 0"></td> <td style="border-width:1px 0 0 0"></td> <td style="border-width:1px 0 0 0"></td> <td style="border-width:1px 0 0 0"></td> <td style="border-width:0"></td> </tr> <tr style="height:14pt"> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> </tr> <tr style="height:14pt"> <td style="border-width:0"></td> <td style="border-width:0"></td> <td align="right" colspan="3" style="border-width:0"><font style="font-size:14pt;">申请人（盖章）</font></td> <td style="border-width:0"></td> <td style="border-width:0"></td> </tr> <tr style="height:14pt"> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0"></td> <td style="border-width:0" colspan="2"><font style="font-size:14pt;">年&nbsp;&nbsp;&nbsp;&nbsp;月&nbsp;&nbsp;&nbsp;&nbsp;日</font></td> </tr> </tbody></table>