<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;广益佳苑二期</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:20pt"> <td values="" style="border-width:0" bindtype="0" rowspan="2" colspan="7" datasource="" type="textarea' styles='line-height:37px"><font style="font-size:14pt;">　　1、广益佳苑二期581+582按幢分摊，已维修完毕，结算金额：55,644.79元，审价<br>费用：0,合计：55,644.79。</font></td> </tr> <tr style="height:20pt"> </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：2021-03-02；结束日期：2021-03-02。</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、无锡市明泽建筑安装工程有限公司</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：2021年03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;">　　甲方</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03月02日至2021年03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;">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">广益家园二期581单元1001室</td> <td align="center">173.4100</td> <td align="center">1,495.25</td> <td align="center">0</td> <td align="center">1,495.25</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">2</td> <td align="center">广益家园二期581单元1002室</td> <td align="center">173.1600</td> <td align="center">1,493.09</td> <td align="center">0</td> <td align="center">1,493.09</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">3</td> <td align="center">广益家园二期581单元1003室</td> <td align="center">174.0000</td> <td align="center">1,500.33</td> <td align="center">0</td> <td align="center">1,500.33</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">4</td> <td align="center">广益家园二期581单元101室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">5</td> <td align="center">广益家园二期581单元102室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">6</td> <td align="center">广益家园二期581单元103室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">7</td> <td align="center">广益家园二期581单元201室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">8</td> <td align="center">广益家园二期581单元202室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">9</td> <td align="center">广益家园二期581单元203室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">10</td> <td align="center">广益家园二期581单元301室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">11</td> <td align="center">广益家园二期581单元302室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">12</td> <td align="center">广益家园二期581单元303室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">13</td> <td align="center">广益家园二期581单元401室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">14</td> <td align="center">广益家园二期581单元402室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">15</td> <td align="center">广益家园二期581单元403室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">16</td> <td align="center">广益家园二期581单元501室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">17</td> <td align="center">广益家园二期581单元502室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">18</td> <td align="center">广益家园二期581单元503室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">19</td> <td align="center">广益家园二期581单元601室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">20</td> <td align="center">广益家园二期581单元602室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">21</td> <td align="center">广益家园二期581单元603室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:16pt"> <td align="center">22</td> <td align="center">广益家园二期581单元701室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">23</td> <td align="center">广益家园二期581单元702室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</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">24</td> <td align="center" style="border-width:1px 0 1px 1px">广益家园二期581单元703室</td> <td align="center" style="border-width:1px 0 1px 1px">101.6100</td> <td align="center" style="border-width:1px 0 1px 1px">876.15</td> <td align="center" style="border-width:1px 0 1px 1px">0</td> <td align="center" style="border-width:1px 0 1px 1px">876.15</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">25</td> <td align="center">广益家园二期581单元801室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">26</td> <td align="center">广益家园二期581单元802室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">27</td> <td align="center">广益家园二期581单元803室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">28</td> <td align="center">广益家园二期581单元901室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">29</td> <td align="center">广益家园二期581单元902室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">30</td> <td align="center">广益家园二期581单元903室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">31</td> <td align="center">广益家园二期582单元1001室</td> <td align="center">173.4100</td> <td align="center">1,495.25</td> <td align="center">0</td> <td align="center">1,495.25</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">32</td> <td align="center">广益家园二期582单元1002室</td> <td align="center">173.1600</td> <td align="center">1,493.09</td> <td align="center">0</td> <td align="center">1,493.09</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">33</td> <td align="center">广益家园二期582单元1003室</td> <td align="center">174.0000</td> <td align="center">1,500.33</td> <td align="center">0</td> <td align="center">1,500.33</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">34</td> <td align="center">广益家园二期582单元101室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">35</td> <td align="center">广益家园二期582单元102室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">36</td> <td align="center">广益家园二期582单元103室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">37</td> <td align="center">广益家园二期582单元201室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">38</td> <td align="center">广益家园二期582单元202室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">39</td> <td align="center">广益家园二期582单元203室</td> <td align="center">101.6100</td> <td align="center">876.15</td> <td align="center">0</td> <td align="center">876.15</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">40</td> <td align="center">广益家园二期582单元301室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">41</td> <td align="center">广益家园二期582单元302室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">42</td> <td align="center">广益家园二期582单元303室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">43</td> <td align="center">广益家园二期582单元401室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">44</td> <td align="center">广益家园二期582单元402室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">45</td> <td align="center">广益家园二期582单元403室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">46</td> <td align="center">广益家园二期582单元501室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">47</td> <td align="center">广益家园二期582单元502室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">48</td> <td align="center">广益家园二期582单元503室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">49</td> <td align="center">广益家园二期582单元601室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">50</td> <td align="center">广益家园二期582单元602室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">51</td> <td align="center">广益家园二期582单元603室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">52</td> <td align="center">广益家园二期582单元701室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">53</td> <td align="center">广益家园二期582单元702室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">54</td> <td align="center">广益家园二期582单元703室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">55</td> <td align="center">广益家园二期582单元801室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">56</td> <td align="center">广益家园二期582单元802室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">57</td> <td align="center">广益家园二期582单元803室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">58</td> <td align="center">广益家园二期582单元901室</td> <td align="center">101.0200</td> <td align="center">871.05</td> <td align="center">0</td> <td align="center">871.05</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">59</td> <td align="center">广益家园二期582单元902室</td> <td align="center">98.0500</td> <td align="center">845.44</td> <td align="center">0</td> <td align="center">845.44</td> <td style="border-width:0 0 0 1px"></td> </tr> <tr style="height:14pt"> <td align="center">60</td> <td align="center">广益家园二期582单元903室</td> <td align="center">101.6100</td> <td align="center">876.14</td> <td align="center">0</td> <td align="center">876.14</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>