As the owner, officer or authorized representative (“Representative”) of the Named Insured under the policy listed herein (the “Policy”), I request that the payments due but not paid during the period between April 27, 2020 and December 31, 2020 be paid over a period of 12 months beginning on February 1, 2021.

To that end, I certify and affirm under the penalties of perjury that the Named Insured is a resident of the District of Columbia.