Is South Dakota Over-Prescribing

Drugs to Native American

Foster Kids?



11/29/12 South Dakota ICWA Directors Special Report



Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 1
Preamble
After an initial investigation we, the South Dakota Indian Child Welfare Act directors, are
alarmed by the possibility that Native American foster children in South Dakota are
receiving harmfully excessive amounts of prescription drugs designed to treat mental
illness. The following quantitative data is cause for concern and an indication that further
research is needed: a majority of South Dakotas foster children are Native American
1
, and
South Dakota spent eleven times more on prescription drugs for Native American foster
care children in 2009 than it did in 1999
2
. The number of prescriptions for Native
American foster children more than tripled during the period
3
.


1
Administration for Children and Families; Adoption and Foster Care Analysis and Reporting System (AFCAR); 1998-
2001, 2002-2005, 2006-2009: http://www.acf.hhs.gov/. For each year, the Administration for Children and Families, a
division of U.S. Health and Human Services, prepares a summary report on child foster abuse and neglect statistics. By
looking on page 364/501 of the CWO 2000 Annual Report, page 380/512 of the CWO 2001 Annual Report, page 420/532 of
the CWO 2002-2005 Annual Report, and page 327/416 of the CWO 2006-2009 Annual Report, we can see that between
2000-2009 over 50% of the Children in South Dakota Foster Care were Native American.
2
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html. To access the data cited above within the Medicaid
Statistical Information System, there are 3 different filter categories to apply: the 'Basis of Eligibility' (BOE), the
'Race/Ethinicity, and the 'Service Type' (e.g. 'pharmaceutical drugs'). In the annual 1999 datamart, we can see that South
Dakota was reimbursed $110,014 for prescription drugs for Native American children. In the 2009 datamart, we can see that
South Dakota was reimbursed $1,227,783, which is more than eleven times the amount from 1999.
3
IBID; When viewing the MSIS data through the filters given in footnote # 2, we can see that the total number of Native
American Children who are receiving prescription drug benefits (claim count from 1999 MSIS Datamart) is 841 in 1999,
whereas by the year 2009 the datamart shows that 3,112 Native American children are receiving those drug benefits, which is
more than three-fold increase the 1999 levels.
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 2

Fig.1

Findings
Finding #1: The State of South Dakota has dramatically increased funding from 1999 to
2009 to support its Department of Social Services (D.S.S.), particularly its Medical Services
Division. There was a massive spike in spending on pharmaceuticals for foster care
children in the middle of these same years. As a consequence of this spending, South
Dakota has the fifth highest ratio of prescriptions to Native American foster children in the
country, when small-sample states (those with fewer than 50 Native American foster
children) and states with a Native American foster child population of less than 0.1% are
excluded
4
(see spreadsheet at end of document).

4
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html. ALSO Administration for Children and Families; Adoption
and Foster Care Analysis and Reporting System (AFCAR); 1998-2001,2002-2005, 2006-2009: http://www.acf.hhs.gov/. To
0
200
400
600
800
1000
1200
1400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Number of Children
(blue)
Number of Claims
(red)
Year
Number of Native American
Children in Foster Care on
Sept. 30th of given year
(Source- Administration for
Children and Families Child
Welfare Outcome Report
data compiled 1999-2009)
Number of Prescription Drug
Claims for Native American
Children in Foster Care
Annually (Source- Medicaid
Statistical Information System,
Center for Medicaid Services,
Department of Health and
Human Services, data
compiled 1999-2009)
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 3
Over the years 1999-2009 the total number of prescriptions given out to Native American foster
children in South Dakota increased from 841 to 3,112, a rise of 370%
5
.
!"#$%&
Source: The Medicaid Statistical Information System, United States Health and Human Services Center for Medicaid
Services, http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html
During the same period, the total amount of federal funding for South Dakotas D.S.S. Medical Services
Division grew by 149.6%
6
, and Medicaid spending for prescription drugs for foster children in the state

compute this data, we analyzed a number of Child Welfare Outcome Reports as well as statistics from the Medicaid
Statistical Information System. The Center for Medicaid Services, under the U.S. Department of Health and Human Services,
manages the Medicaid Statistical Information System. The system was designed to provide comprehensive data across all
states for Medicaid spending. Note: the logic of excluding the small sample states with fewer than 50 Native American foster
children is that the average number of prescriptions given per Native American foster child in those states is highly variable
from year to year. The logic of excluding those with Native American foster child populations of less than .1% is that
complete data is not available for those states.
5
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html. When viewing the MSIS data through the filters given in
footnote # 2, we can see that the total number of Native American Children who are receiving prescription drug benefits
(claim count from 1999 MSIS Datamart) is 841 in 1999, whereas by the year 2009 the datamart shows that 3,112 Native
American children are receiving those drug benefits. This represents an increase between 1999 and 2009 of 370%.
6
South Dakota Governors Budgets, Fiscal Year reports 1999-2000 to 2009-2010 compiled. Some available at
http://bfm.sd.gov/budget/. The Bureau of Finance and Management publishes the Governors recommended yearly budget, as
well as the 'Budget in Brief'. By assessing the reports issued over the years 1999-2009 (some of which are available online at
bfm.sd.gov, and others of which are available upon request from a South Dakota State Librarian), it is observed that the
Department of Social Services has increased its overall funding/spending by 149.6%.
0
1000
2000
3000
4000
Year
Number of Prescription Drug Claims for
Foster Care Children in South Dakota
Annually
Number of Drugs for
Foster Care Children
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 4
increased from $300,987 to $4,016,148, a thirteen-fold increase (or a rise of 1334%
7
). The average
federal contribution comprised two-thirds (65.6%) of the total amount spent
8
.
Fig. 3
Fig. 3 Source: The Medicaid Statistical Information System, United States Health and Human Services Center for
Medicaid Services, http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html
Between 2005 and 2006, the number of prescriptions provided to Native American foster children in
South Dakota via Medicaid funding more than doubled from 547 to 1138, while the amount of federal
Medicaid spending for those prescriptions spiked from $489,631 to $1,002,682. This is a remarkable rise
in pharmaceutical prescriptions for which we, at this time, have no explanation. In every other state for
those years, prescriptions for foster care children merely inched up, stayed the same, or reduced
9
.

7
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html. When viewing the MSIS data through the filters given in
footnote # 2, we can see that the amount of prescription drug reimbursements for all foster care children in South Dakota in
1999 is $300,987, and for the year 2009 the amount rises to $4,016,148. As a percentage increase, South Dakota's federal
Medicaid spending rose 1334%, or by more-than thirteen-times, between 1999 and 2009.
8
Federal Medical Assistance Percentages or Federal Financial Participation in State Assistance Expenditures (FMAP):
http://aspe.hhs.gov/health/fmap.htm. The Federal Medical Assistance Percentages are released each year, which lay out the
percentage of Medicaid expenditures by states paid for by the federal government. By using the data from each report, years
1999-2009, the average federal share comes out to 65.6%, or approximately two-thirds.
9
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Year
Amount of Money Spent by Federal
Government for Pharmaceutical Drugs for
Foster Care Children in South Dakota Annually
Amount
Spent
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 5
Finding #2: Native American children are placed into foster care at much higher rates than
other ethnic groups in the State of South Dakota.
The State of South Dakota places Native American children into foster care at a significantly higher rate
than any other ethnic group. The Administration for Children and Families has produced data every
year from 1999 to the present, and the numbers show that despite composing only 13.4% of the state
population, American Indian children comprise on average 56.3% of the total number of youth in South
Dakotas foster-care system
10
. !
Finding #3: Across the nation, methods for identifying mental illness and determining
appropriate steps for treatment are subpar with respect to ethnic minorities, specifically
for children and the American Indian population
11
.
The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental
Disorders (DSM) to classify mental illnesses. According to Carolyn Barcus, a member of the Society of
Indian Psychologists, many of the criteria found in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR)
12
are biased against minorities, especially those minorities whose culture
differs greatly from mainstream American culture. Barcus writes, Native people may be less inclined to
express emotion, particularly the men. Native people feel as deeply as other people but may have little

Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html. What is given above is a generalized statement about that
data for all other states besides South Dakota. We witness no notable increases in pharmaceutical prescriptions for Native
American children between 2005 and 2006 for those other states.
10
Administration for Children and Families; Adoption and Foster Care Analysis and Reporting System (AFCAR); 1998-
2001,2002-2005, 2006-2009: http://www.acf.hhs.gov/. For each year, the Administration for Children and Families, a
division of U.S. Health and Human Services, prepared a summary report on child foster abuse and neglect statistics. By
taking the number of in-care children and calculating the percentage of them who are Native American during the years
1999 to 2012, and then charting those points, we observe that an average of 56.3% of the in-care children are Native
American in South Dakota.
11
The Council of National Psychological Associations for the Advancement of Ethnic Minority of Interests; Psychological
Treatment of Ethnic Minority Populations; pg. 4-7, 24-28; http://www.apa.org/pi/oema/resources/brochures/treatment-
minority.pdf. The Society of Indian Psychologists argue on pages 25-29/34 of their report that servicing minority populations
requires additional research and development, because currently the methods for diagnosing 'traditional' white Americans are
not appropriate for assessing mental illness in a minority population.
12
DSM-IV-TR- Diagnostic and Statistical Manual of Mental Disorders, 4
th
publication with included Text Revisions. The
Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychologists Association to classify
different types of mental illness. The DSM-IV-TR is the fourth editionit is the most up to date. The DSM-V is expected to
be published in spring of 2013. Website for DSM-http: //dsm.psychiatryonline.org/book.aspx?bookid=22
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 6
experience, or may not value, expressing feelings. Learning [by therapists] to recognize feelings and the
impact of those feelings on [Native peoples] behavior may be part of the therapeutic process
13
.
In 2003, the American Psychological Associations Council of National Psychology Associations for the
Advancement of Ethnic Minority Interests released a report titled Psychological Treatment of Ethnic
Minority Populations, which stated that culturally competent care is generally not provided to Native
Americans
14
.

The Association asserts that current mental health care delivery systems for white
Americans should be modified when made available to Native peoples. This is currently not done; while
some therapists are culturally competent, policies in general have not been modified to accommodate the
mental health needs of Native American communities.
On April 29th, 2002, President George W. Bush formed the New Freedom Commission on Mental
Health (NFC). The NFC was tasked with conducting a comprehensive study of the United States
mental health service delivery system, including public and private sector providers, and advising the
president on methods of improving the system
15
. In its final report
16
the New Freedom Commission
stated that there exist four areas of research for which, as of 2003, scientific knowledge was lacking. Of
these four categories, three clearly are germane to Native American children in foster care: (1) long-term
effects of medications, (2) impact of trauma, and (3) mental health realities for minorities. According to
the Council of Psychological Associations for the Advancement of Ethnic Minority Interest, it is much
more difficult to assess the mental health of a minority person than that of a white person
17
.

13
The Council of National Psychological Associations for the Advancement of Ethnic Minority of Interests; Psychological
Treatment of Ethnic Minority Populations; November, 2003; pg. 26;
http://www.apa.org/pi/oema/resources/brochures/treatment-minority.pdf. Carolyn Barcus, a member of the Society of Indian
Psychologists, argues on page 27/34 of the referenced report that there often exist differences between Native persons
manner of expressing emotions and that of 'traditional' white Americans.
14
IBID
15
Executive Order No. 13263 of April 29, 2002 Section 3 Mission Federal Register Vol. 67 No. 86. This Executive Order
by President Bush empowered the New Freedom Commission on Mental Health (NFC) to issue recommendations to federal
as well as state and local agencies to alter the way they deliver mental health care: http://georgewbush-
whitehouse.archives.gov/news/releases/2002/04/20020429-2.html
16
New Freedom Commission Final Report, July 22, 2012, available
govinfo.library.unt.edu/mentalhealthcommission/report/finalreport/downloads/finalreport.pdf. See footnote # 15 for
description of the "New Freedom Commission on Mental Health." The Commissions final report included six goals for
improving mental health care delivery systems in America.
17
The Council of National Psychological Associations for the Advancement of Ethnic Minority of Interests; Psychological
Treatment of Ethnic Minority Populations, http://www.apa.org/pi/oema/resources/brochures/treatment-minority.pdf. The
Society of Indian Psychologists argue on pages 25-29/34 that to effectively service minority populations we must complete
additional research, because current methods for diagnosing 'traditional' white Americans are not appropriate for assessing
mental illness in certain minority populations.
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 7
Finding #4: The Texas Medication Algorithm Project, and illegal payoffs by the
pharmaceutical industry
Further comments are warranted about the New Freedom Commission on Mental Health. The
commissions final report recommended six goals for states to improve their mental health delivery
systems, and among these was that states implement medication prescription algorithms similar to the
Texas Medication Algorithm Project (TMAP). TMAP was first implemented by the Texas
Department of Mental Health and Mental Retardation in 1997. The project was directed by Steven Shon,
a state employee who received educational grants of $75,000 from numerous pharmaceutical
corporations and was illegally paid by pharmaceutical industry reimbursement managers to promote
TMAP-like systems in other states, such as PennMAP in Pennsylvania
18
.
During the development of TMAP, certain pharmaceutical companies broke the law by soliciting state
officials to have those companies atypical anti-psychotic drugs made the first-line treatment within the
algorithm. Being designated a first-line treatment means guaranteed reimbursement through Medicaid
and markedly increased sales. The pharmaceutical industry was successfully sued more than once in
relation to illegal marketing of antipsychotic drugs, in some cases to child psychiatrists. One example of
a lawsuit over illegal marketing is The State of Texas ex rel. Allen Jones. V. Janssen Pharmaceutica, in
which a document was produced that outlined drug producer Janssen Co.s objective of gaining
favorable Risperdal [a drug made by Janssen] positioning within the TMAP algorithm by paying
$7,000 to support the annual physicians conference in Texas.
19

It is clear that the TMAP project was inappropriately influenced by pharmaceutical industry funding.
We fear that similar influence may have been at play in South Dakota in recent years.
Finding #5: For foster children in South Dakota, there is no replacement for the traditional
policy of parental consent for the administration of psychotropic medications.

18
Jury Trial, State of Texas ex rel. Allen Jones v. Janssen Pharmaceutica, Jury Trial, pages 7-32, available
1boringolaman.com/texas-transcripts/2012-01-12 State v. Janssen vol 4.pdf. The testimony of Nancy Bursch-Smith, a former
"reimbursement manager" for Janssen Pharmaceutica, during the case of The State of Texas ex rel. Allen Jones v. Janssen
Pharmaceutica, in the jury trial pages 7-32, confirms that the pharmaceutical industry lobbied key decision makers in each
state to embrace state-sponsored medication algorithms.
19
IBID; pg. 11-12.
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 8
An extensive survey
20
was conducted in 2007 by the Psychology Department at the University of Illinois
at Chicago to examine various means used by state child welfare agencies to provide consent for, and
oversight of, psychotropic medications for children in state custody
The questionnaire and interviews covered current policies and procedures pertaining to
consent and oversight for psychotropic medications; whether these policies and
procedures are administered at the state or county level; requirements for review of
medication requests or consultation by a licensed health care professional; and use of a
formulary (i.e., an approved list of medications)
21
.

According to the survey results, South Dakota has no policy to provide oversight of the process by
which informed consent is granted for the administration of psychotropic medications to foster
children.
22
Additionally, and remarkably, South Dakota has no policy for provision of medication
request review or consultation by a licensed health care professional for foster care children receiving
psychotropic medicationsand the state does not use a formulary for administering psychotropic
medications
23
. This represents a threat to Native American children, since a majority of foster children
in South Dakota are Native American.
Finding #6: South Dakota appears to have prescribed anti-psychotic drugs to foster
children prior to 2006 even though the FDA had not approved the use of these drugs by
children at that time. And after 2006, South Dakota seems to have overprescribed these
agents to children.
Another concern we have as ICWA directorsone which we will be further researchingis that there
were zero FDA-approved uses for atypical anti-psychotics for children prior to 2006 (even after 2006,

20
The University of Illinois at Chicago, Psychology Dept.; Child Welfare, VOL. 86, #5, pg. 181: Psychotropic
Medication Management for Youth in State Care: Consent, Oversight, and Policy Considerations; September/October 2007
http://www.psych.uic.edu/ijr/pdf/mnaylor/PsychotropicMedicationsWards.pdf. The University of Illinois at Chicago
Psychology Department released a report in 2007 regarding psychotropic medication use by youth in state-run programs. The
researchers gathered data about "current policies and procedures pertaining to consent and oversight for psychotropic
medications; whether these policies and procedures are administered at the state or county level; requirements for review of
medication requests or consultation by a licensed health care professional; and use of a formulary".
21
IBID
22
IBID
23
IBID
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 9
FDA-sanctioned uses have been narrowly tailored
24
). So, if in fact the D.S.S. in South Dakota approved
the offering of atypical antipsychotics to foster children prior to 2006, they were doing so off label. It
is not illegal for a doctor to prescribe a drug for an off-label use to a child, but that childs parent or legal
guardian must provide consent. As explained, the consent procedures in South Dakota are inadequate, so
off-label prescribing to foster childrenif it has been going onhas put Native foster children at risk.
The type of risk which we are concerned about was trumpeted in a 2011 Government Accountability
Office (GAO) study.
25
The study asserts that serious overprescribing of anti-psychotics by states to
foster children has been occurring. The study spawned a scathing report by ABC News on
overprescribing to foster care children nationwide
26
.
We are unable to determine whether anti-psychotic drugs have been prescribed in large numbers to
Native American foster children in South Dakota, because this information is kept private by the state.
However, we have the most recently available Pharmaceutical & Therapeutics Committee Report from
South Dakota, and it indicates that the drug agent with the highest Medicaid reimbursement rate in
South Dakota, by far, is anti-psychotics
27
.

24
Mathis, Mitchell V. M.D., Atypical Antipsychotics and Pediatrics, U.S. Food and Drug Administration, Office of New
Drugs,http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/PediatricAdvisoryCommittee/UC
M193200.pdf. The only approved uses for atypical antipsychotic medications by adolescents prior to 2009 were for (1)
schizophrenia and (2) bipolar mania. Those two mental illnesses are found in less than 1% of the population in America, yet
they account for about 1/4th of all spending to treat mental illnesses according to the National Institute of Mental Health
(NIMH- http://www.nimh.nih.gov/index.shtml).
25
United States Government Accountability Office; Foster Children: HHS Guidance Could Help States Improve Oversight
of Psychotropic Prescriptions; December 1, 2011
26
ABC World News with Diane Sawyer; New Study Shows U.S. Government Fails to Oversee Treatment of Foster
Children With Mind-Altering Drugs; November 30, 2011; http://abcnews.go.com/US/study-shows-foster-children-high-
rates-prescription-psychiatric/story?id=15058380#.UJgH24WGZnJ
27
South Dakota Department of Social Services; Medicaid P & T Committee Report; June 22, 2012. The most recent
available report from the South Dakota Department of Social Services Pharmaceutical&Therapeutics Committee Report
details the extent to which antipsychotics are reimbursed via state Medicaid programs. The report shows the astonishingly
high rate of reimbursement for atypical antipsychotics over any other therapeutic class.
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 10
Fig. 4
Source: Medlcald &1 CommlLLee 8eporL, prepared by PealLh lnformaLlon ueslgns lnC 31 May 2012, avallable from
hLLp://www.hldlnc.com/asseLs/flles/sdmedlcald/dur-handouLs/Su-6-12-ack.pdf
This is circumstantial evidence that foster children in South Dakota are being prescribed anti-psychotics.
Additionally, the average cost per eligible Medicaid claim for a child in South Dakotas foster care
system for the year 2005 was $1,133.49. This is more than three times higher than the Medicaid cost for
a child in the general state population, for whom the average cost was $351.51
28
. Because anti-
psychotics are much more expensive than most other pharmaceuticals
29
, this also indicates that our
Native foster children have likely been receiving anti-psychotic medication, before 2006 and after.


28
United States Health and Human Services Center for Medicaid Services; The Medicaid Statistical Information System;
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html.
29
South Dakota Department of Social Services; Medicaid P & T Committee Report; June 22, 2012. See footnote # 27.
Native American Children and Prescription Drug Use in the South Dakota Foster Care System


Page 11
Conclusion
The activity of the South Dakota Department of Social Services with respect to enabling and authorizing
the administration of pharmaceutical drugs to Native American children in foster care clearly merits
further investigation.


!"#$#%& '()*%+,-.,/0123+%4,14 '()*%+,-.,/0123+%4,14,.-5#%+,/$+% 6%+/%4#$7%,-.,82$59$,'$#1:%;
,5#$#%,<-<(2$#1-4=,>??@ ,!$5,-.,"%<#A,B?#0=,>??@&=,.+-),C0123,D%2.$+%, '$#1:%,8)%+1/$4,,/0123+%4,,14,.-5#%+,/$+%,
!C%45(5,E(+%$(,5#$#15#1/5& ,"())$+1%5,-.,8CF,CDG,G(#/-)%5,H%<-+# !$5,-.,"%<#A,B?#0=,>??@&
C-2-+$3- IIJJKLB L>BM IAI?N
O$45$5 @PMJMP @>BI IAB?N
Q#$0 L?>M?B >BPM KA@?N
G92$0-4$ LP>@MJ IIJKL LAL?N
"-(#0,R$9-#$ IPJ?>L I@KP MIAI?N
'%*+$59$ KMMJI> @IPB LAB?N
C$21.-+41$ PKMM>IL JLI>J ?AL?N
82$59$ ILKMPI IPI? KPA@?N
'-+#0,C$+-214$ >I@KBPP II>?> IAP?N
S1/017$4 >KLKLP? >?>>J IA??N
'-+#0,R$9-#$ IKBJPK IBP? >@AL?N
D$50147#-4 IMBJ>>I I?MKK LA??N
S-4#$4$ >IPBLB >?IP B>A??N
S155-(+1 IKB>>>L I?>L@ ?AM?N
T-U$ JIIL?@ PBLM IAL?N
D15/-4514 IB>LML? J@PM BAJ?N
S144%5-#$ I>@M?BI @L@K I>AI?N
G+%7-4 L@?MKI I?@@L PAP?N
'%U,S%V1/- M?I?@P >BJP JAI?N
T3$0- K???JJ ILMJ @A@?N
'%U,W-+9 KMBJJBP B?>?B ?A>?N
8+1X-4$ I@K>>PL PJLL >AM?N
!5#$#%5,*%2-U,#015,214%,0$:%,2%55,#0$4,M?,'$#1:%,8)%+1/$4,/0123+%4,14,#0%1+,.-5#%+,/$+%,5Y5#%),-4,"%<#A,B?#0=,>??@&
DY-)147 I>BKB? IBBM IAB?N
'%U,Z%+5%Y >?LJ@KJ I?JB> ?A>?N
[%V$5 @MIJ@KI B?@BB ?AI?N
8+9$45$5 @PJLJL BM?@ ?A>?N
G01- >JL>@IK I@BKK ?A>?N
"-(#0,C$+-214$ I?M?I?> KPI> ?A>?N
O%4#(/9Y I??@JPB JJI? ?AI?N
S$+Y2$43 IBJ@@BJ P?KI ?AI?N
'%:$3$ @KMLIJ M?ML ?AJ?N
\-(151$4$ I?@MK@I M>J? ?AB?N
82$*$)$ II>IMI@ @PK? ?A>?N
6%445Y2:$41$ >LB?I>P >IBPM ?A>?N
T431$4$ IMLJIL? IIKLP ?A>?N
R%2%U$+% >?K>IB IIII ?AK?N
H0-3%,T52$43 >BJBKJ >PIP IA>?N
S$14% >L@PMP >?JP IAB?N
S$55$/0(5%##5 IKMJMB> I>?L? ?AI?N
]$U$11 >P?PPP >BL@ ?AB?N
C-44%/#1/(# L>PMI@ @K?J ?AI?N
R15#+1/#,-.,C-2()*1$ IIKMPP >BII ?A??N
!5#$#%5,*%2-U,#015,214%,0$:%,2%55,#0$4,?AIN,-.,#0%1+,.-5#%+,/0123,<-<(2$#1-4,'$#1:%,8)%+1/$;82$59$,'$#1:%,-4,"%<#A,B?#0=,>??@&
[%44%55%% IK@J?IK LMJB 2%55,#0$4,?AIN
^1+7141$ IL>P?PP JLP? 2%55,#0$4,?AIN
6(%+#-,H1/- I?ILBBL @L@> 2%55,#0$4,?AIN
D%5#,^1+7141$ BLLIBM KI@L 2%55,#0$4,?AIN
S155151<<1 J@?@KJ B>BI 2%55,#0$4,?AIN
F2-+13$ K?@M@P@ >PKLP 2%55,#0$4,?AIN
T2214-15 B>?B@?@ IPIP> 2%55,#0$4,?AIN
_%-+71$ >KJL?J> IBBBM 2%55,#0$4,?AIN
'%U,]$)<501+% B?B>MP IIBJ 2%55,#0$4,?AIN
^%+)-4# IBBMKK IBP> 2%55,#0$4,?AIN
!"#$#%& '(#)*$#%+,-,./$#)-0+-1+2/$(3$+4$#)5%6 4.*7%8+-1+.0)9.%+:/$)*(+1-8 ;$#)-+-1+,8%(:8),#)-0+<8.=+:/$)*(
4$#)5%+2*%8):$0+:>)/<8%0+)0+1-(#%8+:$8% +,8%(:8),#)-0+<8.=+8%)*7.8(%*%0#( +,%8+4$#)5%+2*%8):$0+:>)/<
+!$(+-1+"%,#?+@A#>B+CAAD& 5)$+E%<):$)<+1-8+2/$(3$+4$#)5%6 #-+0.*7%8+-1+4$#)5%+2*%8):$0
+:$/:./$#%<+7F+.()0=+,%8:%0#$=% 4$#)5%+2*%8):$0+:>)/<8%0+ +:>)/<8%0+)0+1-(#%8+:$8%+
+-1+%#>0):+=8-.,+#-+#>%+0.*7%8+-1 )0+1-(#%8+:$8%+!GE"+<$#$& !-0+$+=)5%0+<$#%B+"%,#+@A#>+-1+%$:>+F%$8&
+1-(#%8+:$8%+:>)/<8%0+-0+#>$#+($*%+<$#%
G-/-8$<- HI @IJ @?KDIJ@LKDC
M$0($( LI CCK C?NDJK@CAHH
O#$> IIA CAD I?LNCNCNCN@
P3/$>-0$ IA@K INHA I?N@IIKIIHH
"-.#>+Q$3-#$ LK@ II@L I?@KHHKADLL
4%78$(3$ JIK DLD I?@@KD@A@J
G$/)1-80)$ DCJ NDK I?CCCK
2/$(3$ HKN IA@L I?AHDAHCHCJ
4-8#>+G$8-/)0$ CI@ C@C I?ALHCAILNL
E):>)=$0 CAC CAC I
4-8#>+Q$3-#$ @N@ @D@ A?HN@IHA@KH
R$(>)0=#-0 LKK LIJ A?HDJD@HLI
E-0#$0$ DKD JNK A?LLLJKKLHC
E)((-.8) JI KJ A?LLC@JCHKI
S-T$ IDH ICJ A?N@HDKKHN
R)(:-0()0 CLJ IH@ A?DNNIHCHLC
E)00%(-#$ L@I KNI A?JDDNLNAAK
P8%=-0 IAJD JDA A?J@A@A@A@
4%T+E%U):- IDH LJ A?JACHJLJL
S<$>- IC@ JK A?K@HACK@H
4%T+V-83 DA CC A?@DDDDDDDN
28)W-0$ CKJ C A?AALID@CDJ
!(#$#%(+7%/-T+#>)(+/)0%+>$5%+/%((+#>$0+JA+4$#)5%+2*%8):$0+:>)/<8%0+)0+#>%)8+1-(#%8+:$8%+(F(#%*+-0+"%,#?+@A#>B+CAAD&
RF-*)0= IN ICI N?IINDKNAJH
4%T+X%8(%F CI I@H D?DIHAKNDIH
Y%U$( @I IKH K?LADKJIDI@
283$0($( N CK @?KCLJNIKCH
P>)- @@ N@ C?CICICICIC
"-.#>+G$8-/)0$ IA IH I?H
M%0#.:3F L IJ I?LNJ
E$8F/$0< H IA I?IIIIIIIII
4%5$<$ @J @@ A?HKCLJNIK@
Z-.)()$0$ ID IC A?NJ
2/$7$*$ IK N A?J
[%00(F/5$0)$ K@ IK A?@CJJLI@HJ
S0<)$0$ C@ D A?CDALDHJDJ
Q%/%T$8% K I A?CJ
;>-<%+S(/$0< @J C A?AJNIKCLJN
E$)0% CN A A
E$(($:>.(%##( IC A A
\$T$)) N A A
G-00%:#):.# D A A
Q)(#8):#+-1+G-/.*7)$ A A A
!(#$#%(+7%/-T+#>)(+/)0%+>$5%+/%((+#>$0+A?I]+-1+#>%)8+1-(#%8+:>)/<+,-,./$#)-0+4$#)5%+2*%8):$62/$(3$+4$#)5%+-0+"%,#?+@A#>B+CAAD&
Y%00%((%% /%((+#>$0+H CK /%((+#>$0+C?DDN
^)8=)0)$ /%((+#>$0+L CD /%((+#>$0+@?CJ
[.%8#-+;):- /%((+#>$0+N 06$ 06$
R%(#+^)8=)0)$ /%((+#>$0+K I /%((+#>$0+A?CJ
E)(()(),,) /%((+#>$0+@ II @?DDDDDDDDN
_/-8)<$ /%((+#>$0+CH JH C?A@KKLCNJH
S//)0-)( /%((+#>$0+IH CI I?IAJCD@IJL
`%-8=)$ /%((+#>$0+I@ IJ I?IJ@LKDIJK
4%T+\$*,(>)8% /%((+#>$0+I @ /%((+#>$0+@
^%8*-0# /%((+#>$0+I I /%((+#>$0+I