<table border="0" cellpadding="0" cellspacing="0" width="448" style="border-collapse:
 collapse;table-layout:fixed;width:336pt">
 <tbody><tr height="20" style="height:15.0pt">
  <td colspan="3" height="20" class="xl65" width="192" style="border-right:.5pt solid black;
  height:15.0pt;width:144pt">&nbsp;</td>
  <td colspan="2" rowspan="2" class="xl67" width="128" style="border-right:.5pt solid black;
  border-bottom:.5pt solid black;width:96pt">&nbsp;</td>

 </tr>
 <tr>
  <td rowspan="3" height="60" class="xl71" style="border-bottom:.5pt solid black;
  height:45.0pt;border-top:none">&nbsp;</td>
  <td colspan="2" rowspan="2" class="xl67" style="border-right:.5pt solid black;
  border-bottom:.5pt solid black">&nbsp;</td>

 </tr>
 <tr>
  <td colspan="2" height="20" class="xl65" style="border-right:.5pt solid black;
  height:15.0pt;border-left:none">&nbsp;</td>

 </tr>
 <tr">
  <td colspan="2" height="20" class="xl65" style="border-right:.5pt solid black;
  height:15.0pt;border-left:none">&nbsp;</td>
  <td colspan="2" class="xl65" style="border-right:.5pt solid black;border-left:
  none">&nbsp;</td>

 </tr>
 <tr>
  <td colspan="5" rowspan="2" height="20" class="xl67" style="border-right:.5pt solid black;
  border-bottom:.5pt solid black;height:30.0pt">&nbsp;</td>

 </tr>
 <tr></tr>

</tbody></table>

table {
  border-collapse: collapse;
  margin-bottom: 10px;
}
td {
  border: 1px solid black;
}