Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following six boxes. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following six boxes. Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/Estate Limited liability company

Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Address (number, street, and apt. or suite no.)

City, State, and ZIP code

Social Security/Employer Identification Number

Under penalties of perjury, I certify that: Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and I am a U.S. citizen or other U.S. person (defined below); and The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Authorization Name

Date

Individual/Company Name

Individual/Company Address

City

State

Zip Code

Individual/Company Contact Name

Email Address

Bank Name

Bank Address

Routing Number

Account Number

Authorization Signature (Full Name)

Date

Printed Name of Signatory (Full Name)

Title