**JOHNSON & GINS**

**D. F. O., 30Y 5024**
NEW YORK, NEW YORK
(212) 764-7500

**JNTL BUSINES MACHINES LIMP**
ATTN MR J M COSTELLO IMS DEPT
20WC PURCHASE STREET
PURCHASE NY
10577

**BSD NO:** 04742
**MAIL TO:** PAPER
**FUNCTION:** 1
**BILL TYPE:** PREMIUM
**INCOME CALC:** SPTRM
**SHARE:** NONE
**CURRENCY:** USD
**ORIG INV:** 2157740
**SUSPENSE:** 0
**ISSUE:** 260925-00003
**INSTALLMENT PERIODS:** 12
**DEPOSIT:** 76,455.00
**CONTROL NO.:** 009778

**CLIENT NO:** 260925-00003
**INVOICE NO:** 2157740
**DATE:** 05/21/13
**AMOUNT:** 76,455.00

**DEPARTMENT:** COL
**CAE:** MICHEL T.
**POLICY NUMBER:** COL3278670
**DESCRIPTION:** DEPOSIT PREMIUM
**AMOUNT:** 76,455.00
**CLASS B:** 402464
**POL VER:** 1
**INS CO:** PACE
**PATEE:** 1
**COMMISSION:** 0
**COMM RATE:** 0
**LOC:** 1
**TAX:** 0
**TOTAL:** 76,455.00
**PAYABLE:** DAILY

**JOHNSON & HIGGINS**
**FORM NO:** 1990A
**MM:** 009778