JAY AES - PACKAGE ORDER FORM November 2012

LOGO JAY AES - PACKAGE ORDER FORM November 2012 Account: QTY Option # QTY Option # SEATING SYSTEMS PACKAGES SEATING SYSTEMS PACKAGES PKG10XX Universal/E-Z Mount Seating Package $1,053.75 MOD1180 1 Stimulite Honeycomb, Seat $214.00 PKG11XX Universal Mount Seating Package $1,042.00 MOD1495 1 Pudgee Foam Partial Insert $147.25 PKG13XX Universal Space-Saver Seating Package $1,042.00 MOD1595 5/8 Gel Partial Insert $142.00 PKG20XX Adj J Hook Bracket Seating Package $787.50 MOD1160 Elasto-Gel Addition, Seat $57.25 PKG23XX Ind Adj J Hook Brkt Seating Package $825.00 MOD0050 Omit Foam in Seat $0.00 PKG24XX Ind Adj J Hook Brkt Seating Pkg, Contour $1,129.00 MOD1200 2 HR Foam in Seat $25.20 PKG30XX E-Z Mount Seating Package $972.00 MOD1300 MOD1400 3 HR Foam in Seat 1 Pudgee Foam in Seat $39.25 $198.25 BASIS SEATING SYSTEM PACKAGES MOD1500 MOD1525 Gel over HR Foam in Seat Cubed Gel over HR Foam in Seat $181.25 $210.00 PKG50XX BASIS Seat/Back pkg $543.75 MOD1600 1 T-Foam in Seat $79.50 PKG51XX BASIS Seat/Back pkg w/adjustable hinge $903.00 MOD1605 1/2 T-Foam in Seat $45.50 PKG52XX BASIS Seat/Back pkg; contoured $607.50 MOD1615 1-1/2 T-Foam in Seat $96.50 PKG53XX BASIS Seat/Back pkg w/adj hinge; contoured $965.75 MOD1700 2 T-Foam in Seat $113.50 PKG52XXLK BASIS Seat/Back pkg, Li'l Kiddos $724.00 MOD1800 1 SunMate Foam in Seat $67.75 PKG53XXLK BASIS Seat/Back pkg contoured, Li'l Kiddos $1,090.75 MOD1805 MOD1815 1/2 SunMate Foam in Seat 1-1/2 SunMate Foam in Seat $34.00 $84.75 HARDWARE MOUNTING KITS FOR USE WITH BASIS PACKAGES; PRICED AS KITS MOD1900 MOD5150 2 SunMate Foam in Seat Incontinent Film Covering $101.75 $76.25 HMK0010 HMK0011 HMK0011T Universal/EZ Mount Universal Universal w\ Transport Option* $485.50 $504.50 $780.25 SEAT MODIFICATIONS STRUCTURAL HMK0020 Adjustable J Hook $253.25 MOD4150 Notches for Back Posts N/C HMK0023 Adjustable Flush Hook $204.50 MOD4175 Mid Seat Cutout for X-Brace $83.75 HMK0030 EZ Mount $426.00 MOD4180 Foam Form Seat $375.00 HMK0040 Li l Kiddos $610.50 MOD4200L Offset Seat, Long on Left side $89.00 HMK0040T Li l Kiddos w\ Transport Option* $794.00 MOD4200R Offset Seat, Long on Right side $89.00 HMK0055 Flush Hook $189.75 MOD4300 MOD4400 T-style Seat Anti-Thrust Seat $94.25 $135.75 SEATING SYSTEM MODIFICATIONS MOD4450 MOD4460 Quick-Fit Anti-Thrust Seat Wedge Seat $328.50 $151.50 MOD1045 Include Adj Offset Hinge, Wide in Pkg $64.75 MOD4500 Cubed Seat (2x2x2 HR foam) $323.25 MOD1055 Include Adj Offset Hinge, Ped in Pkg $64.75 MOD4525 Custom Cubes, Seat $381.50 MOD6800 Transport Option Hardware $276.50 MOD4600 MOD4620 Contour Seat Sculptured Seat $272.50 $823.00 SEAT INSERT PACKAGES MOD4625 Upcharge for Foam Mold, Seat $79.00 SSK10XX Universal/E-Z Mount Seat Package $569.25 SSK20XX Adj J Hook & Rotate Hold Seat Package $348.75 SSK27XX FW Adj J Hook & Rotating Hold seat Pkg $348.75 SSK30XX E-Z Mount Seat Package $463.25 SSK50XX Drop Hook & Rotate Hold Seat Package $286.25 SSK55XX FW Flush Hook & Rotate Hold Pkg $327.50 SSK60XX Drop Hook & Fixed Hold Seat Package $286.25 SSK70XX Li l Kiddos Seat Insert Package $666.75 SSK71XX Li l Kiddos Contour Seat Package $861.75 SEAT MODIFICATIONS - UPHOLSTERY MOD4125 Attaching Strips, Bottom, Hook & Loop $27.50 MOD4126 Attaching Strips, Top, Hook & Loop $27.50 MOD5120 Add Velcro Closure, Custom $116.50 MOD5130 Add Synthetic Sheepskin To Cover, Std $142.00 MOD4630 Quick-Fit Contoured Seat $411.25 MOD4640L Lateral Reinforcement, Seat, Left $86.00 MOD4640R Lateral Reinforcement, Seat, Right $86.00 MOD4650 Substitute ABS for Multi-Ply in Seat $115.50 MOD4655L Belt Strap Notches, Seat, Left $19.00 MOD4655R Belt Strap Notches, Seat, Right $19.00 MOD4700 Built-in Medial Thigh Support $134.00 MOD4725 Contour Lateral Adductor $134.00 MOD4800 Seat Rail Foam Overlay $106.00 MOD4825 Seat - Front Edge Bevel Undercut $108.00 MOD4900 Adjustable Split Seat $369.00 MOD5000 I-style Seat $96.50 MOD5700 Substitute 3/4 Multi-Ply for 1/2 $54.00 MOD8000 Omit T-Nuts N/C MOD9005 Pre-Fit Modification, Seat $79.50 MOD9050 Oversize, over 20 up to 24 $63.50 MOD9075 Oversize, over 24 up to 28 $83.75 MOD5190 Custom Fabric Upcharge, Seat $74.25 MOD9000 Other Custom Seat Modifications QUOTE ADDITIONAL SEAT COVERS COV4100 COV4109 COV4110 Additional Zippered Cover, Flat, Standard Additional Zippered Cover, Custom Additional Slip Over Cover, Flat, Standard $106.00 $143.00 $106.00 Specifications are subject to change without notice. Copyright @2008 15 REV.B

COV4119 Additional Slip Over Cover, Custom $143.00 Specifications are subject to change without notice. Copyright @2008 25 REV.B

BACK INSERT PACKAGES BACK MODIFICATIONS - INTERNAL SBK10XX Universal Mount Back Package QUOTE SBK12XX Drop Hook & Fixed Hold (Between) QUOTE SBK20XX Adj J Hook & Fixed/Rotate Hold (Forward) QUOTE SBK21XX Adj J Hook & Fixed Hold (Forward) QUOTE SBK22XX Adj J Hook & Fixed/Rotate Hold (Between) QUOTE SBK23XX Adj J Hook & Fixed Hold (Between) QUOTE SBK24XX Mount Hook & Fixed Hold (Forward) QUOTE SBK25XX E-Z Mount Back Package QUOTE SBK70XX Li l Kiddos Back Package $769.50 SBK71XX Li l Kiddos Contour Back Package $941.25 BACK MODIFICATIONS FOAM MOD0055 Omit Foam in Back N/C MOD2180 1 Stimulite in Back $218.00 MOD2200 2 HR Foam in Back $25.50 MOD2300 3 HR Foam in Back $39.25 MOD2400 1 Pudgee Foam in Back $198.25 MOD2405 Additional.5 Pudgee Foam in Back $135.75 MOD2500 Gel & HR Foam in Back $181.25 MOD2600 1 T-Foam in Back $79.50 MOD2605 1/2 T-Foam in Back $46.50 MOD2615 1-1/2 T-Foam in Back $96.50 MOD2700 2 T-Foam in Back $113.50 MOD2800 1 SunMate Foam in Back $67.75 MOD2805 1/2 SunMate in Back $34.00 MOD2815 1-1/2 SunMate in Back $84.75 MOD2900 2 SunMate Foam in Back $101.75 BACK MODIFICATIONS STRUCTURAL MOD4645L Lat Reinforce, Contour/Sculptured; left $86.00 MOD4645R Lat Reinforce, Contour/Sculptured; right $86.00 MOD5180 Foam Form Back $362.00 MOD5200 I-style Back $96.50 MOD5300 T-style Back $96.50 MOD5425 Half-Round Lumbar Roll $142.00 MOD5450 Adj Angle Bi-Angular Back w/ 2 brkts $272.50 MOD5451 Adj Angle Bi-Angular Back w/ 1 brkt $181.25 MOD5460 Adjustable Lumbar Back $294.75 MOD5500 Curved Back $133.50 MOD5501 Curved Back, w/ 2 hinged L Brkts $151.50 MOD5502 Curved Back, w/ 4 Hinged L Brkts $181.25 MOD5525 Rear Upright Foam Overlay $102.75 MOD5530 Curved Foam Addition to Flat Back $102.75 MOD5550 Cubed Back (2x2x2 HR foam) $323.25 MOD5575 Custom Cubes, Back $381.50 MOD5600 Sewn Anterior Positioning Strap Slots $84.75 MOD5650 Substitute ABS for Multi-Ply in Back $142.00 MOD5700 Replace 3/4 Multi-Ply with 1/2 $54.00 MOD5800 Contour Back $237.50 MOD5801 Quick-Fit Contour/Bi-Angular Back $448.50 MOD5802 Quick-Fit Contour Back Only $369.00 MOD5803 Sculptured Back $823.00 MOD5823 Upcharge for Foam Mold, Back $85.00 MOD5850 Scapular Contour Cutout, Back $147.25 MOD8100 Omit T-Nuts, Back N/C MOD9105 Pre-Fit Modification, Back $79.50 MOD9150 Oversize, over 20 up to 24 $63.50 MOD9175 Oversize, over 24 up to 28 $83.75 FTK10XX Thoracic Support Kit, Foam Form, 5H x 5D $243.00 FTK11XX Thoracic Support Kit, Foam Form, 7H x 5D $243.00 FTK12XX Thoracic Support Kit, Foam Form, 9H x 6D $243.00 FTK13XX Thoracic Support Kit, Foam Form, 11H x 7D $243.00 FTK19XX Thoracic Support Kit, Foam Form, Custom $255.00 BACK MODIFICATIONS UPHOLSTERY MOD5125 Add Velcro Closure, Custom $116.50 MOD5135 Add Synthetic Sheepskin To Cover, Std $142.00 MOD5195 Custom Fabric Upcharge, Back $74.25 MOD5610 Shoulder Strap Mounting Grommets $114.50 MOD5620 Attaching Ties for Back, Velcro $20.25 MOD5621 Attaching Ties for Back, Snaps $19.00 MOD5900 Monogram Back, Block N/C MOD5901 Monogram Back, Script N/C MOD9100 Other Custom Modifications, Back $88.00 ADDITIONAL BACK COVERS COV5100 Additional Zippered Cover, Flat, Standard $106.00 COV5109 Additional Zippered Cover, Custom $143.00 COV5110 Additional Slip Over Cover, Flat, Standard $106.00 COV5119 Additional Slip Over Cover, Custom $143.00 LATERAL THORACIC SUPPORT PACKAGES Specify pad size. Order 2 for complete pair. LTK22XX Standard profile bracket $138.75 LTK24XX Med/High profile bracket $138.75 LTK25XX E-Z Access (swing-away) bracket $268.25 LTK30XX E-Z Access and Front Adjust bracket $328.50 LTK35XX Rear Quick Adjust (RQA) bracket $286.25 LTK37XX E-Z Access and RQA bracket $332.75 LTK40XX Reverse Offset Bracket $148.50 LTK45XX Removable Bracket $270.25 LTK47XX Removable & RQA Bracket $318.00 LTK72XX Li l Kiddos standard profile brkt $110.25 LTK75XX Li l Kiddos E-Z Access bracket $257.50 LTK76XX LI l Kiddos Rear Quick Adjust brkt $261.75 LTK77XX Li l Kiddos E-Z Access and RQA brkt $283.00 LATERAL THORACIC SUPPORT MODIFICATIONS MOD2550 1/4 Gel in Thoracic Support $38.25 MOD2650 1/2 T-Foam in Thoracic Support $28.50 MOD2750 1/2 Pudgee in Thoracic Support $38.25 MOD2850 1/2 SunMate in Thoracic Support STANDARD MOD2950 Taper Front Edge of Thoracic Support $14.75 MOD3000 Replace Multi-Ply with ABS $9.50 MOD3100 Add Waterfall Foam to Thoracic Support $39.25 MOD3150 Contour-Fit Pad $49.75 MOD3175 Hinged Pad $111.25 MOD5510 Curved Lateral Pad $16.00 Specifications are subject to change without notice. Copyright @2008 35 REV.B

LATERAL THORACIC ADDITIONAL HARDWARE AND COVERS MEDIAL THIGH SUPPORT PACKAGES HDW2025 1/4 Bracket Spacer $17.00 HDW2050 1/2 Bracket Spacer $17.00 HDW2521 1 Height Adapter Plate $25.50 HDW2522 2 Height Adapter Plate $25.50 HDW2523 3 Height Adapter Plate $25.50 COV2656 Lateral Bracket Fabric Cover $27.50 LATERAL PELVIC/THIGH SUPPORT PACKAGES LPK22XX LPK27XX Standard profile brkt, pad up to 5Hx18L Removable Brkt, pad up to 5Hx18L $116.50 $251.25 LPK31XX 15º Med/High Profile Brkt, pad up to 5Hx18L $140.00 LPK32XX Med/High Profile brkt, pad up to 5Hx18L $116.50 LPK33XX 20º Adj Removable brkt, pad up to 5Hx18L $288.25 LPK55XX 1 Reverse Offset Brkts, pad up to 5Hx18L $140.00 LPK57XX 20º Adj fixed Brkt, pad up to 5Hx18L $220.50 LPK72XX Li l Kiddos standard profile brkt, pad to 5H x 14L $127.25 LPK76XX Li l Kiddos High Profile Brkt, pad to 5H x 14L $127.25 LPK40XX Lat Pelvic/Thigh Arm Combo w/fixed Brkt $260.75 LPK41XX Lat Pelvic/Thigh Arm Combo w/rem Brkt $379.50 LPK42XX Lat Pelvic/Thigh Arm Combo w/rem, Hgt Adj $462.25 LATERAL PELVIC/THIGH SUPPORT MODIFICATIONS MOD3050 Replace Multi-Ply with ABS $9.50 MOD3055 Contoured Pelvic Supports (Anti-Thrust) $39.25 MOD3550 1/4 Gel in Pelvic Support $38.25 MOD3551 1/4 Gel in Long Pelvic Support $45.50 MOD3650 1/2 T-Foam in Pelvic Support $28.50 MOD3750 1/2 Pudgee in Pelvic Support $41.25 MOD3850 1/2 SunMate in Pelvic Support STANDARD MOD4750L Long, Curved Pad, Pelvic/Thigh left $17.00 MOD4750R Long, Curved Pad, Pelvic/Thigh, right $17.00 ADDITIONAL DISTAL HARDWARE NOTES HDW2527 2 Distal Ext Adapter Bar $26.50 HDW2528 3 Distal Ext Adapter Bar $26.50 MTK10XX MTS w/ Swing-Away brkt, 5 or 7 arm $378.50 MTK20XX MTS w/ Swing-Away brkt, 5 or 7, Custom Quote MTK50XX Adj height Swing-Away brkt, 2-3 $425.00 MTK55XX Adj height Swing-Away brkt 2-3, Custom Quote MTK60XX Adj height Swing-Away brkt, 3-4.5 $425.00 MTK65XX Adj height Swing-Away brkt, 3-4.5, Custom Quote MTK70XX Adj Hideaway L Mount, 1.5-3 $518.25 MTK71XX Adj Hideaway L Mount, 1.5-3, Custom Quote MTK72XX Adj Hideaway T Mount, 1.5-3 $518.25 MTK73XX Adj Hideaway T Mount, 1.5-3, Custom Quote MTK74XX Adj Hideaway L Mount, Short $546.00 MTK75XX Adj Hideaway L Mount, Short, Custom Quote MTK76XX Adj Hideaway L Mount, Tall $546.00 MTK77XX Adj Hideaway L Mount, Tall, Custom Quote MTK31XX LK Pull-Away brkt, 1.25 to 2.75 adj $413.50 MKT33XX LK Pull-Away brkt, 1.25 to 2.75 adj, custom QUOTE MTK34XX LK Pull-Away brkt, 2.75 to 4.25 adj $413.50 MTK35XX LK Pull-Away brkt, 2.75 to 4.25 adj, custom Quote MTK93XX Pull-Away brkt, 1.5 to 2 adj $445.25 MTK94XX Pull-Away brkt, 1.5 to 2 adj, Custom Quote MTK95XX Pull-Away brkt, 2 to 3.5 adj $445.25 MTK96XX Pull-Away brkt, 2 to 3.5 adj, Custom Quote MTK97XX Pull-Away brkt, 3.5 to 5.5 adj $445.25 MTK98XX Pull-Away brkt, 3.5 to 5.5 adj, Custom Quote MEDIAL THIGH SUPPORT MODIFICATIONS MOD3555 1/4 Gel in Medial Support $101.75 MOD3655 1/2 T-Foam in Medial Support $28.50 MOD3855 1/2 SunMate Foam in Medial Support STANDARD ANTERIOR PELVIC POSITIONING BELTS SINGLE PULL APB6212 1.5 Side Release buckle, Small Pads $56.00 APB6213 1.5 Side Release buckle, Med Pads $56.00 APB7212 1.5 Push-Button buckle, Small Pads $86.00 APB7213 1.5 Push-Button buckle, Med Pads $86.00 APB5115 Li l Kiddos 1 buckle, 4.5 Pads $91.00 APB5116 Li l Kiddos 1 buckle, 5.5 Pads $91.00 APB5117 Li l Kiddos 1 buckle, 7.5 Pads $91.00 ANTERIOR PELVIC POSITIONING BELTS DUAL PULL APB6222 1.5 Side Release buckle, Small Pads $56.00 APB6223 1.5 Side Release buckle, Med Pads $56.00 APB7222 1.5 Push-Button buckle, Small Pads $86.00 APB7223 1.5 Push-Button buckle, Med Pads $86.00 APB5125 Li l Kiddos 1 buckle, 4.5 Pads $91.00 APB5126 Li l Kiddos 1 buckle, 5.5 Pads $91.00 APB5127 Li l Kiddos 1 buckle, 7.5 Pads $91.00 ANTERIOR PELVIC POSITIONING BELTS MEDIAL 4-POINT APB7242 1.5 Push-Button buckle, Small Pads $111.00 APB7243 1.5 Push-Button buckle, Med Pads $111.00 APB7244 1.5 Push-Button buckle, Large Pads $111.00 APB5145 Li l Kiddos 1 Push-button buckle, 3.5 Pads $111.00 APB5146 Li l Kiddos 1 Push-button buckle, 4.5 Pads $111.00 Specifications are subject to change without notice. Copyright @2008 45 REV.B

ANTERIOR TRUNK SUPPORTS CLASSIC STYLE FOOT & ANKLE POSITIONING ATS8100 Dynamic, X-Small $152.00 ATS8101 Dynamic, Small $152.00 ATS8102 Dynamic, Medium $152.00 ATS8103 Dynamic, Large $152.00 ATS8104 Dynamic, X-Large $152.00 ATS8107 Dynamic, Early Intervention $152.00 ATS8300 Structured, X-Small $152.00 ATS8301 Structured, Small $152.00 ATS8302 Structured, Medium $152.00 ATS8303 Structured, Large $152.00 ATS8304 Structured, X-Large $152.00 ANTERIOR TRUNK SUPPORTS CONTOUR STYLE ATS9100 Dynamic, X-Small $152.00 ATS9101 Dynamic, Small $152.00 ATS9102 Dynamic, Medium $152.00 ATS9103 Dynamic, Large $152.00 ATS9104 Dynamic, X-Large $152.00 ATS9107 Dynamic, Early Intervention $152.00 ATS9300 Structured, X-Small $152.00 ATS9301 Structured, Small $152.00 ATS9302 Structured, Medium $152.00 ATS9303 Structured, Large $152.00 ATS9304 Structured, X-Large $152.00 LOWER EXTREMITY POSITIONING KPG10XX Knee Positioning Blocks, + Pullaway Hardware $397.50 KPG19XX Knee Positioning Blocks, Custom + Hardware $452.50 TST7014L Single Leg/Foot Box, Std, 14 W/C (left leg) $244.00 TST7014R Single Leg/Foot Box, Std, 14 W/C (right leg) $244.00 TST7016L Single Leg/Foot Box, Std, 16 W/C (left leg) $244.00 TST7016R Single Leg/Foot Box, Std, 16 W/C (right leg) $244.00 TST7018L Single Leg/Foot Box, Std, 18 W/C (left leg) $244.00 TST7018R Single Leg/Foot Box, Std, 18 W/C (right leg) $244.00 TST7114 Full Width Leg/Ft Box, Std, 14 W/C (1 pc) $382.00 TST7116 Full Width Leg/Ft Box, Std, 16 W/C (1 pc) $382.00 TST7118 Full Width Leg/Ft Box, Std, 18 W/C (1 pc) $382.00 TST6001 Shoe Holder, padded buckles, Small $71.00 TST6101 Shoe Holder, padded buckles, Medium $71.00 TST6201 Shoe Holder, padded buckles, Large $71.00 TST6301 Shoe Holder, padded buckles, Extra-Large $71.00 TST6510L Foot & Ankle Positioner, Small, left $91.00 TST6510R Foot & Ankle Positioner, Small, right $91.00 TST6520L Foot & Ankle Positioner, Medium, left $91.00 TST6520R Foot & Ankle Positioner, Medium, right $91.00 TST6540L Foot & Ankle Positioner, Large, left $91.00 TST6540R Foot & Ankle Positioner, Large, right $91.00 TST6560L Foot & Ankle Positioner, Extra-Large, left $91.00 TST6560R Foot & Ankle Positioner, Extra-Large, right $91.00 UPPER EXTREMITY POSITIONING PRODUCTS CHOOSE: SLOTS NO SLOTS WCT1005 Wooden Support Platform, X-Small $197.00 WCT1000 Wooden Support Platform, Small $197.00 WCT2000 Wooden Support Platform, Medium $197.00 WCT3000 Wooden Support Platform, Large $209.00 WCT4000 Wooden Support Platform, X-Large $209.00 WCT5005 Lexan Support Platform, X-Small $209.00 WCT5000 Lexan Support Platform, Small $209.00 WCT6000 Lexan Support Platform, Medium $209.00 WCT7000 Lexan Support Platform, Large $224.00 WCT8000 Lexan Support Platform, X-Large $224.00 WCT9000 Custom Support Platform $386.00 PLATFORM MOUNTING HARDWARE THW1000 Toggle Hardware $48.00 THW2000 Slide Tube Hardware $143.00 THW3000 Birch Runners $30.00 THW3100 S-style Runners, ABS $30.00 THW3210 Slotted Channel Runners, ABS $34.00 THW3500 Adjustable Lever Mount Hardware $91.00 THW3700 Top Drop Platform $91.00 THW4000 Cam Style Hardware $34.00 THW4500 Angle-Cam Hardware $44.00 PLATFORM ACCESSORIES TAC11XX Platform Padding, Removable Cover $256.00 TAC4100L Joystick Cutout, Left $51.00 TAC4100R Joystick Cutout, Right $51.00 TAC4150 Joystick Midline Cutout $104.00 TAC4175 Platform Cutout, Custom $59.00 THW6000 Strap with Release Buckle $38.00 NOTES Specifications are subject to change without notice. Copyright @2008 55 REV.B