_______________________

(Covered Entity Name)

(Date) _____________

Notice of Exemption

In accordance with 23 NYCRR § 500.19(e), (Covered Entity Name) hereby provides notice that (Covered Entity Name) qualifies for the following Exemption(s) under 23 NYCRR § 500.19 (check all that apply):

□ Section 500.19(a)(1)

□ Section 500.19(a)(2)

□ Section 500.19(a)(3)

□ Section 500.19(b)

□ Section 500.19(c)

□ Section 500.19(d)

If you have any question or concerns regarding this notice, please contact:

(Insert name, title, and full contact information)

(Name) _______________________ Date: ______________________

(Title)

(Covered Entity Name)

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