Pellumb Olaj

Homes and Neighbourhoods 
Islington Council Municipal Offices 
222 Upper Street 
London 
N1 1XR 

Our Ref: 
Your Ref: 

Coroner ME Hassell 
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court 
By email to: 

1 August 2025  

Dear Coroner Hassell 

Re:  London  Borough  of  Islington  response  to  the  Regulation  28  Prevention  of  future 

death report (3 June 2025) into the death of Pellumb Olaj 

Firstly, we would like to reiterate our deepest condolences, and those of the Council, to the family 
of Mr Olaj. 

In order to provide a clear and substantive response to the PFD report, we consider that it will 
assist the Chief Coroner to set out some background, including a synopsis of some procedural 
matters at the hearing, as well as to explain evidence that could have been given, if so permitted, 
during the hearing. 

Inquest hearing 

Prior to the Inquest Islington Council asked if the Coroner was seeking a written statement from 
any Council officer, but was advised by the Coroner’s Office that it was not required. The Coroner 
did  not,  therefore,  have  the  benefit  of  detailed  evidence  in  relation  to  local  authority  housing 
provision and/or housing management. Only oral evidence was therefore available at the hearing. 
However,  the  oral  evidence  permitted  during  the  hearing  was  significantly  and  unexpectedly 
limited.  

Representatives from Islington Council at the inquest hearing comprised three Islington Council 
officers  (the  Assistant  Director  for  Housing  Needs,  the  Assistant  Director  for  Housing 
Management,  and  an  Income  Recovery  Officer),  and  Counsel  for  Islington.  All  three  Islington 
Council officers were listed in the witness list provided by the Coroner’s Officer the day before the 
hearing. During the hearing, oral evidence was provided by two of the three Council Officers in 
attendance. However, the Coroner unanticipatedly decided not to call the third council officer, the 
Assistant Director for Housing Management, thereby significantly limiting the evidence provided. 
The Assistant Director for Housing Management, had she given oral evidence, would have been 
able to speak to the management changes (as further described below). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Islington Council only became an Interested Person at the start of the inquest hearing. It became 
evident at the outset of the hearing that there was an apparent assumption from the Coroner that 
Islington  Council  was  an  Interested  Person.  This  assumption  was  corrected  by  Counsel  for 
Islington, who was asked to immediately confirm whether Islington Council wished to become an 
Interested Person. Prior to that interaction, there was no previous indication that it would have 
been in any way appropriate for Islington Council to become an Interested Person.  

Chronology 

We have attached to this letter an appendix of documents.  At pages 1 and 2 of the appendix 
appears  a  chronology  of  events  which  summarises  pertinent  details  from  prior  to  the  offer  of 
accommodation being made, until beyond Mr Olaj’s death. At no point either around the time of 
the offer of accommodation being made, nor subsequently, were any concerns raised to Islington 
by  anyone,  including  Mr  Olaj’s  treating  primary  care  physician,  psychiatrist  and  specialist 
occupational therapist, about the location of his home on the 6th floor. Importantly, a review of its 
suitability could have been requested at any time in the years thereafter. As said by 
at the hearing, when she reviewed Mr Olaj in June 2022, he indicated that he was happy with his 
flat, and seeing his children. 

Action taken since Mr Olaj’s death 

There are a number of procedural changes that Islington has implemented/is implementing. Some 
of  these  were  already  in  progress  prior  to  the  death  of  Mr  Olaj.  Despite  the  impetus  of  these 
actions not being related to the death of Mr Olaj, the aims of the actions are such that they can 
be  identified  as  addressing  concerns  arising  out  of  his  death.  For  other  actions  identified,  the 
impetus behind the change was Mr Olaj’s death. 

Actions that were already in progress – for existing tenants 

A re-organisation of the Housing Management Service.  

The service redesign includes: 

i.  A  single  point  of  contact  for  residents  to  raise  concerns  with  a  named  and  directly 
contactable housing officer.  The aim is to ensure that the tenancy team is more accessible 
to residents. 

ii.  Smaller  patch  sizes.  Officers  are  to  be  allocated  patch  sizes  of  up  to  600  properties  per 
senior  housing  officer  (reduced  from  up  to  1,400).  The  aim  is  that  this  will  enable  more 
proactive and less reactive contact to residents with live issues. Additionally, it will allow for 
officers to be able to provide a more dedicated period to each of the tenants, building positive 
professional relations. 

iii. A  strategy  within  the  new  structure  for  the  named  officer  to  complete  effective  tenancy 
audits,  with  all  tenants  and  leaseholders  (approximately  36,000  residents)  being  visited 
within three years. This will allow for vulnerable tenants to be identified, enabling appropriate 
support and referrals to be made. Prioritisation of audits is based on a number of data points 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 including known vulnerabilities. On the audit form itself, it is stated: “By completing this form, 
we  can  better  understand  the  needs  and  concerns of our  residents  and  take appropriate 
action to address any issues that may arise.” A copy of the audit form appears at pages 3 – 
20 of the appendix to this response.  

The restructure report was completed on 7 August 2024 and updated on 23 September 2024. 
Tenancy audits commenced on 9 June 2025. Implementation of the new structure commences 4 
August 2025.  

It is anticipated that all of the above changes will work to improve the service for all residents. 
Existing tenants experiencing mental health and other challenges will be more easily identified 
and therefore supported appropriately.  

Actions that were already in progress – for new tenants 

A re-organisation of the Housing Needs Service.  

It had been identified that the internal process from an applicant applying as homeless, through 
to  being  offered  a  secure  tenancy,  was  fractured,  due  to  the  different  teams  involved.  It  was 
considered that this process could be made more streamlined, allowing for all the officers involved 
in  the  process  to  sit  within  one  larger  team.  Accordingly,  a  number  of  functions  delivered  by 
officers  within  Housing  Management  (Targeted  Duty  Manager,  Targeted  Duty  Team,  Principal 
Tenancy  Officer,  and  Targeted  Duty  Team  Tenancy  Officer),  were  shifted  across  to  Housing 
Needs. Therefore, in practice, all the steps from applying as homeless through to the sign up of 
a new tenancy now fall within a single service. This allows for information regarding applicants, 
including  any  potential  mental  health  or  other  needs,  to  be more  easily  shared  throughout  the 
process.  

It is anticipated that the above organisational changes will work to improve the service for all new 
tenants. As the officers will now all be working within one service, it is expected that the needs of 
all  new  tenants,  including  those  with  mental  health  and  other  challenges,  will  be  known  to  all 
officers  engaged  during  the  process,  such  that  they  can  be  taken  into  account  throughout, 
including when an offer of accommodation is made. The re-organisation will also result in all the 
officers dealing with the case, from the initial date of application, through to the sign up of the new 
tenancy, having access to the same database. 

The report establishing these organisational changes is dated 6 August 2024. Implementation of 
the new structure commenced on 1 April 2025 and concluded on 2 June 2025.  

Actions that have been initiated since Mr Olaj’s death - for existing tenants 

Changes to IT systems. 

Currently,  the  Housing  Needs  Service  and  the  Housing  Management  Service  use  a  single 
database with access to two modules that are inaccessible to one another. Prior to the inquest, it 
was  identified  that  allowing  access  to  the  two  modules  for  both  services  would  ensure  that 
information obtained by the Housing Needs Service during the homelessness application process 

3 

 
 
 
 
 
 
 
 
 
 
 
 is more easily accessible to the Tenancy Management service. This change will allow for officers 
within  the  Housing  Management  service  to  access  records  developed  during  the  application 
process. Once the change is implemented, officers within the Housing Management Service will 
be able to check the computer system to locate information about a tenant’s medical history, such 
that there is a continued awareness of issues that were of previous and possibly ongoing concern.  

This issue was first discussed with Islington Council’s Digital Services team prior to the inquest. 
A meeting was subsequently arranged, which took place on 15 July 2025. The Digital Services 
team  are  now  looking  into  how  this  request  can  be  developed  into  reality.  Whilst  the 
implementation of this proposed change has yet to materialise, the issue had been identified and 
raised with Digital Services following the death of Mr Olaj and prior to the inquest hearing.  

Actions that have been initiated since Mr Olaj’s death - for new tenants 

i.  New procedure for specialist psychiatric advice. 

A  new  procedure  has  been  identified  and  now  implemented,  regarding  the  requirement  for 
specialist  psychiatric  evidence  to  be  obtained  where  it  becomes  apparent  during  the 
homelessness  application  process  that  an  applicant  has  a  mental  health  condition  and/or  has 
previously attempted to end their life. This new procedure was identified and proposed wording 
discussed with the Legal Team on 7 May 2025. The procedure was subsequently finalised and 
implemented  on  10  July  2025.  Whilst  implementation  of  the  procedure  postdates  the  inquest 
hearing, the identification of the procedure and an intention to implement such would have been 
explained at the hearing, should the opportunity have arisen. A copy of the finalised procedure 
appears at pages 21 – 22 of the appendix to this response. 

ii.  Amended internal form. 

Amendments  to  an  internal  form  have  now  been  implemented.  The  form  is  used  to  gather 
information about a homeless applicant’s needs and determine the type of housing to be offered 
to the individual to enable the Council to discharge its housing duty under the Housing Act.   

The amendments made to the form are to explicitly highlight any medical needs encompassing 
either  the  physical  and/or  mental  health  needs  of  any  person/s  in  the  household  that  is  to  be 
rehoused. This information along with other information within the form is considered holistically 
by the housing officer before an offer of social housing is made to the individual.   

Whilst the introduction of the amended form postdates the inquest hearing, identification of the 
changes planned were first discussed on 7 May 2025. This would have been explained at the 
hearing, should the opportunity have arisen. A copy of the amended form appears at pages 23 – 
29 of the appendix to this response. 

Conclusion 

We trust that the information in this response provides some reassurance to the Chief Coroner 
that Islington Council does indeed take its responsibilities as a social landlord seriously and that 

4 

 
 
 
 
 
 
 
 
 
 
 
 any mental  health  and  other needs of new and existing  tenants  is considered  when  allocating 
accommodation and thereafter. 

It does also seem prudent to highlight that the availability of Council accommodation is extremely 
limited, especially accommodation on the ground and first floor.  Some applicants and tenants 
with physical disabilities may not be able to physically access accommodation that is above the 
ground  floor  and  their  needs  must  also  be  considered  when  suitable  accommodation  does 
become available. 

The information and evidence set out in this response was available at the inquest hearing and 
would  have  been  heard  by  way  of  oral  evidence,  had  the  opportunity  been  provided.  It  is 
somewhat  unfortunate  that  there  was  no  opportunity  at  the  inquest  hearing  for  any  of  this 
information to be shared. It is possible that, had it been provided, the matters of concern raised 
by the Coroner in the PFD report would have been addressed.  

Yours sincerely 

Assistant Director Housing Needs  

Assistant Director Housing Management 

5 

 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 APPENDIX TO ISLINGTON COUNCIL’S RESPONSE TO THE PREVENTION OF 
FUTURE DEATHS REPORT 

CHRONOLOGY 

Date 

2013 

Narrative 

Mr Olaj was initially a Joint tenant of 
, Islington Council landlord. 

7 July 2020  Following a relationship breakdown that included reports of domestic abuse, 
Mr Olaj made a homeless approach (supported by mental health services) to 
Islington Housing Aid Centre. A homelessness application form was 
accepted and assigned for enquiries.  

9 July 2020  

 at the North Islington Rehab and Recovery Team 
(Specialist Occupational Therapist) was asked to complete a medical 
assessment form for Mr Olaj.  
A GP summary was also requested from his GP to ensure robust enquiries 
were made into his circumstances.  

9 July 2020  The completed medical assessment was provided alongside a letter from Mr 

Olaj’s psychiatrist detailing his psychiatric history.  
In response to the question “what type of accommodation do you feel you 
 stated that Mr Olaj “has access to his children, he 
need” 
has parental responsibility and will need a 2 bedroom flat, so his children can 
visit and stay over”. There was no mention of a requirement for a ground 
floor flat.  
The Medical Assessment Form and the clinic letter were referred to the 
Council’s medical advisers at NowMedical who advised on housing needs.  
The Homelessness Application Form was completed by the housing officer 
assigned to Mr Olaj. The diagnosis of paranoid schizophrenia was recorded, 
together with details of his treatment (monthly injections). Details were also 
recorded about his mobility issues arising from a stroke suffered in 2014. 
The form also set out a Daily Living Assessment which recorded that Mr Olaj 
could communicate well. 
The Council’s medical adviser recommended that Mr Olaj be housed on 
medical grounds. The medical advisor further advised that Mr Olaj’s housing 
needs were for a “first floor maximum if un-lifted or any floor with a lift”. 
A Personalised Housing Plan was co-produced with Mr Olaj. The plan 
recorded his medical issues, and advised that he needed self-contained 
accommodation, either a studio or one-bedroom flat that was affordable 
(Local Housing Allowance). 
3 weeks after Mr Olaj approached LBI, his case was agreed (as statutorily 
homeless) and he was nominated to view 

. 

4 weeks after his initial homeless application, Mr Olaj signed his tenancy 
agreement for the property at 

 which was located on the 6th floor in a lifted 

building. No concerns were raised at this point or subsequently by Mr Olaj, 
or his treating primary care physician, psychiatrist or specialist occupational 
therapist, about the location of the accommodation on the 6th floor.  

10 July 
2020 
10 July 
2020 

13 July 
2020 

13 July 
2020 

22 July 
2020  

27 July 
2020 

1 
 
 
 Date 

Narrative 

27 July 
2020 

July 2020 – 
29 October 
2024 

30 October 
2024 

30 October 
2024 

30 October 
2024 

30 October 
2024 

1 November 
2024 
24 February 
2025 

5 March 
2025 

A letter was sent to Mr Olaj confirming a telephone appointment for 27 
August, the purpose of the call was stated to include addressing any 
concerns.  
A number of interactions were made during this time between Mr Olaj and 
Islington, all regarding low level rent arrears. There is no record of any 
indication of any concerns being raised about the suitability of the 
accommodation during this period.  
Mr Olaj contacted the Income Recovery team (within Housing Management) 
in a state of confusion to complain about his GP. This was over 4 years after 
he moved to his property at Turnpike House. He was in arrears of less than 
£50.00 and no action was being taken against him due to his arrears.   
The officer who spoke to him provided oral evidence at the inquest hearing 
about the call.  
Following the call, the officer spoke to a manager and informed him of the 
call and that she had called the emergency services. That manager has now 
left LBI, but the case notes state that the manager contacted the tenancy 
and intensive teams, who confirmed that Mr Olaj was not known to them. 
The manager emailed a support worker to ask if they could engage with Mr 
Olaj, he also emailed two estate co-ordinators requesting the caretaker 
attend the property and he called Mr Olaj’s next of kin. 
The officer who had taken the call from Mr Olaj received a call from the 
police whilst the police were at the property. The police confirmed that they 
would attend the officer’s home; she was not informed of Mr Olaj’s death 
until the police attended her home later that day.  
The death was also reported by the police to the Council’s Community 
Safety Team on 30 October. The information was conveyed to the Director 
of Public Health on the same day.  
A letter was sent to residents of Turnpike House signposting them to support 
available which included a specialist local bereavement support service. 
An email was sent to the Coroner’s PA from the Public Health team 
regarding this and 3 subsequent suicides. The email included the following: 
“We are alerting you to this situation in case it is of any value in your 
investigation of the deaths, and also to ask you to inform us if your 
investigation identifies any link […] Public Health are coordinating the 
borough’s response to try and prevent further deaths by a similar means, 
and understanding any possible link between these cases would inform that 
work.” 
A response was received from the Coroner requesting further details, which 
were provided on the same date. The Public Heath team have confirmed 
that they received no further communication from the Coroner’s office.  

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20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Procedure: Considerations prior to an offer of housing for applicants with a 
mental health condition 

Date: 10 July 2025 

Officers impacted by this procedure change: 

1.  Prevention and Relief team 
2.  Tenancy Support and Move on team 

Background 

1.  This procedural note has been drafted following the tragic death of a social housing tenant who 

died by suicide in October 2024.  

2.  The tenant became known to the Housing Needs service following a homeless approach in July 
2020. He was housed following his homeless approach into a social housing property by late 

July 2020. Prior to the offer of housing, the Council had received information about his health 

needs which primarily related to his mental health.  

3.  One of the reports received mentioned previous suicidal attempts. Medical advice was sought 

as to his housing needs as well as advice from a mental health specialist OT who supported him 

by completing the requisite forms.  

4.  The advice sought was from a general practitioner and not a psychiatrist. This meant that the 
offer of social housing did not account for his previous history of attempts to end his life.  

5.  The tenant was offered accommodation on the 6th floor of a council estate and remained living 

there until his passing in October 2024.  

6.  A coroner's inquest was held on 3 June 2025 and determined that his death might have been 
prevented if the council had taken greater account of the risks of harm given his poor mental 

health history. In light of the coroner's findings, this procedural note for all officers noted at the 

top of this page must be adhered to for all onward offers of housing for new tenants.  

21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Actions to be taken by housing officers 

In the event that you receive an application (Part 7 application under the Housing Act 1996) and the 

applicant or third party has highlighted, or it otherwise becomes known during the application process, 

that they: 

1.  have a mental health condition and/or 
2.  made previous attempts to end their life 
there are two potential courses of action to take. 

The table below lists the two potential courses of action to take: 

i)  Where an applicant has a named worker/advocate for their mental health needs  
ii)  Where an applicant does not have a named worker/advocate for their mental health needs  

i) Where an applicant has a named 

ii) Where an applicant does not have a named 

worker/advocate for mental health needs 

worker for mental health needs 

1.  You must ask the named worker to complete 
a risk assessment before making an offer of 

1. You must seek medical advice from the 

Council’s medical adviser.  

housing.  

2.  If the risk assessment completed identifies 
any concerns regarding suicide risk, the 

2. The advice sought from the Council’s medical 
adviser or other medical professional must be 

from one with psychiatric expertise. The advice 

advice sought from the Council’s medical 

sought should pose an explicit question about 

adviser or other medical professional must 

the applicants onward housing need and the 

be from one with psychiatric expertise. The 

type of property required.   

advice sought should pose an explicit 

question about the applicants onward 

3. Following receipt of the medical advice, a 

housing need and the type of property 

Suitability Assessment form that considers the 

required. 

medical advice must be completed before the 

offer of housing is made to the homeless 

3.  Following receipt of the medical advice, a 

applicant.  

Suitability Assessment form that considers 

the medical advice must be completed before 

the offer of housing is made to the homeless 

applicant.  

Author: 

/ AD Housing Needs 

Date: 10 July 2025 (v.1) 

Review date: 9 July 2027 

22 
 
 
 
 
 
 
 
 
 
 
 
 www.islington.gov.uk/housing 

Accommodation 

Suitability assessment checklist 

The following issues must be considered prior to allocating a property to a homeless household. 

1.  Employment 

A: Details/discussions with 
client 

B: Officer notes 

Is the applicant or any 
family member 
working? 

Who is your 
employer? (please 
provide full address of 
place of work) 

What is your weekly/ 
monthly income?  

Are you able to work 
from home, if so for 
now many days? 

What is the nature of 
their employment? 

What are the 
worker(s) current 
hours/shift patterns? 

Current travel time 
and cost? 

How far is the 
proposed 
accommodation from 
the place of work? 

23 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Future travel time and 
cost (based on 
proposed new 
address)? 

2.  Childcare 

A: Details/discussions with 
client 

B: Officer notes 

Who provides current 
childcare and how far 
is it from current and 
proposed address? 

Availability of 
childcare in new area? 

Cost of current/future 
childcare? 

3.  Caring 

A: Details/discussions with client  B: Officer notes 

responsibilities/or 
care received 

Does the client or 
any other family 
member have caring 
responsibilities or 
receive care? 

If yes, is this a 
formal or informal 
arrangement? 

Who do they care 
for/or Who cares for 
them and are they in 
receipt of carer’s 
allowance? 

Is there anyone else 
who can care for this 
person or provide 
care to them 
(Investigate 
alternatives)? 

What specific duties 
does the carer 
perform and at what 
times of day? 

24 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Distance of person 
cared for or 
providing care, from 
proposed new 
accommodation? 

4.  Education 

A: Details/discussions with 
client 

B: Officer notes 

Does the client or 
any member of the 
family attend formal 
education? 
School/College or 
University? 

What is the location 
of the 
school/college? 

What school years 
are the children in 
(key educational 
stages)? 

Do any of the 
children attend 
additional schooling 
– cultural, language 
or religious schools? 

How would the 
children travel to 
their current school 
from the new 
address?  

What is the 
availability of spaces 
in the new area 
(check with local 
education 
department)? 

Are you able to study 
from home or do you 
have to attend your 
place of study? 

25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  Medical, 

A: Details/discussions with client  B: Officer notes 

professional 
support and 
safeguarding 
issues 

Does anybody in 
the household have 
any medical needs 
for which they are 
receiving specialist 
treatment? 

Is there anyone in 
the household who 
has been diagnosed 
with a physical or 
mental health 
condition? (yes or 
no) 

If someone in the 
household has been 
diagnosed with a 
physical or mental 
health condition, 
please state the 
name of condition. 

Where do they 
receive 
treatment/support? 

Distance of medical 
services from old 
and new property?  

Possibility for 
transfer to hospital 
in new area?  

Are there any child 
protection 
concerns?  

Please give details  

Are there any 
medical factors that 
need to be 
considered when 
allocating a settled 

26 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 home? 

Does any 
reasonable 
adjustments or 
additional support 
need to be provided 
to enable the 
household to settle 
in their new home? 

6.  Family, social 

A: Details/discussions with client  B: Officer notes 

and community 
support issues 

Does the client and 
their family 
currently receive 
support from other 
family members in 
Islington or in 
other areas? Please 
give details  

Does the client and 
their family 
currently have 
social/ community 
links in Islington or 
in other areas?  

Please give details 

Do the clients or 
any members of 
their family 
currently attend a 
place of worship 
(please provide 
details)?  

Is the client or any 
members of their 
household at risk in 
any specific area? 

27 
 
 
 
 
 
 
 
 
 
 
 Income 

Household wages 

Maintenance/child support 
Company pension 
Student loan/grant 
Other income- please specify 

Benefits 
Income Support 
Jobseeker’s Allowance 
Working Tax Credit 
Incapacity Benefit 
Disability Living allowance/ personal 
independence payment 
DWP deductions/budgeting 
loans/short term advance 
Child Tax Credit 
Child Benefit 
Pension Credit 
Bereavement benefit 
Carers’ allowance 
Housing Benefit/Local Housing 
allowance 
Council Tax support 
Student loan/grant 
Other state benefits-please specify: 

Total monthly income 

Expenditure 

Average 
monthly 
amount 

Average 
monthly 
amount 

Mortgage payments including 
protection 
policy 
Rent 
Building and content insurance 
Council Tax 
Gas 
Electricity 
Water rates 
TV license 
Phone (Mobile, Landline, Internet) 
Travel 
Groceries and other household costs 
Clothing and shoes 
Prescriptions, dentist and opticians 
costs 
After school clubs and children’s 
activities 
Childcare costs/ adult care costs 
Pet costs 
Debts and arrears 
Rent/mortgage arrears 
Unpaid council tax 
Fuel debts 

Credit cards and loans 
Magistrates fines 
Child maintenance 
Credit cards and loans 
Total monthly expenditure 

Income and expenditure self-assessment form                                   

Changes to welfare benefits and the introduction of the household cap have meant that housing costs may 
no longer be covered by housing benefit. In order for us to help you find a housing solution that is 
affordable for you it would help to have an estimate of your monthly household  

I agree that the information contained in this checklist is correct and a true reflection 
of my current circumstances.  

I understand that this information will be used by the council to source suitable 
accommodation for me and my household.  

Name and signature of applicant:                         Name and signature of Council Officer:  

Name in Print:                                                          Name on Print:  

28 
 
 
                                        
 
 
 
                                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Signed:                                                                    Signed:  

Date:                                                                       Date:  

29