2017 APPLICATION FOR REGISTRATION AS A USA TRACK & FIELD AUTHORISED ATHLETE S REPRESENTATIVE. I,, hereby apply to (Full name)

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1 APPLICATION FOR REGISTRATION AS A USA TRACK & FIELD AUTHORISED ATHLETE S REPRESENTATIVE I,, hereby apply to (Full name) USA Track & Field, Inc. (USATF), the IAAF Member Federation for the United States ( IAAF Member Federation ), for Authorization as an Athlete s Representative ( AR ) pursuant to the IAAF Athletes Representatives Regulations ( AR Regulations ) and Regulation 25 of the USATF Governance Handbook ( Regulation 25 ). Before making and signing this, I have received and read the AR Regulations, the Standard Athlete/AR Agreement (the Standard Agreement ), current copies of which have been provided to me along with this, and Regulation 25 governing USATF Authorized Athlete Representatives, a copy of which is available on the USATF website, and which are incorporated herein by reference. I agree to be bound by and conform to the AR Regulations. I ask that my answers to the following questions be considered as part of this Application. I understand that absolute and complete candour is required and that any false, misleading or incomplete statement in an answer on this may result in the denial, suspension, withdrawal or revocation of my Authorization as an AR. I understand and acknowledge that any violation of IAAF Rules or Regulations or any breach of any agreement entered into with any IAAF Member Federation or Athlete in my capacity as an AR may result in a revocation of my Authorization as an AR. I understand that this Application and the answers, statements and information I have provided are designed to benefit the Athletes and IAAF Member Federations by helping to ensure qualified representation. I unconditionally agree that the information contained herein may be maintained and used by IAAF Member Federations in performing their functions and may be provided by IAAF Member Federations to individual Athletes and Meeting Organizers. I understand that only those persons authorized and, where applicable, recognized by IAAF Member Federations as an AR will be permitted to represent Athletes in performing services described in the AR Regulations and Regulation 25. I understand and agree that every agreement for the performance of an AR s services which I enter into with an Athlete (including any modification, extension or renewal of an agreement) shall and must be in the form of the Standard Agreement set out in Appendix 3 of the AR Regulations. It is understood that addenda and amendments to the form are permitted as long as they are consistent with the intent of the said Standard Agreement. (This will include addenda, amendments and modifications as a result of negotiations between the Athlete and the Athlete s Representative relating to compensation and further relating to any provisions that must be amended to conform with the laws of the country under which the agreement is entered into.) If I am granted Authorization, I will save and hold harmless the IAAF Member Federations and the IAAF, their officers, employees and representatives from any liability whatsoever resulting from my acts of commission or omission in providing services to any Athlete in connection with his individual compensation negotiations with any entity or in connection with any subsequent enforcement of such individual contract, which shall include any liability related to income reporting and income tax withholding and remittance to the United States Internal Revenue Service and the corresponding agencies of any country in which I operate as an agent, in which any Athlete resides or in which any Athlete earns income. If I am denied Authorization or if subsequent to obtaining Authorization it is revoked, withdrawn or suspended pursuant to the AR Regulations and Regulation 25, I agree that the exclusive remedy

2 2 in any such case is through the procedure set forth in the AR Regulations. Further and notwithstanding the foregoing, I agree that the exclusive forum for any action arising out of any complaint made by an athlete against me or any complaint that I may make against an athlete or any dispute between the IAAF Federation Member and me (including with respect to the payment, non-payment or delayed payment of money) shall be the dispute resolution procedure set forth in Regulation 21 and/or 25 of the USATF Regulations. I agree to be bound by and to follow the laws, including any application anti-doping rules, applicable to the IAAF Member Federation in the jurisdiction where this Application has been made and also the laws applicable to those IAAF Member Federations in whose jurisdiction I have subsequently been recognized, and the United States Anti-Doping Agency ( USADA ). I agree that such rules have been applicable to me throughout any period in which I served as an athlete, coach, Authorized Athlete Representative and/or athlete support personnel. In the event it is alleged that I have violated any such rule(s), and regardless of whether my alleged rule violation took place before or after submission of this Application, I agree to submit any dispute concerning such rule violation(s) to binding arbitration under the rules of the IAAF Member Federation, the IAAF and/or USADA. By applying, I also agree to be bound by the Ted Stevens Olympic and Amateur Sports Act of 1998 and any and all applicable federal, state, and local laws, executive regulations, rules, and orders of properly constituted government officials in carrying out my obligations. I further agree to be bound by all of the IAAF Member Federation s current and future policies and procedures, including the USATF Code of Ethics (the Code ), USATF SafeSport Handbook and the Agent Code of Conduct, and that breach of said policies may result in the revocation of my certification as a IAAF Member Federation Authorized Athlete Representative. I understand and recognize that this Application and any subsequent Authorization must be made in accordance with the AR Regulations. In consideration for being accorded the opportunity to obtain Authorization status, I further agree that this Application and the Authorization, if one is issued to me, and the AR Regulations, shall constitute a contract between me and USATF, the IAAF Member Federation. I agree to pay to the IAAF Member Federation that is responsible for Authorization any reasonable administrative or other fee that may be assessed for ARs. I understand that I am required to fully and properly complete this Application and that my failure to do so prior to the Application filing deadline may result in denial of my Application. I also agree that, if any changes occur in any answer to any of the questions in this Application, I shall file an amended answer with the IAAF Member Federation in a prompt manner and in no event exceeding sixty (60) days from the time of the change in the answer. I hereby authorize the IAAF Member Federation or its agent, to conduct a confidential criminal background investigation on me, as a pre-condition to its authorization for me to serve as a USATF Authorized Athlete Representative in the sport of track and field. I will cooperate fully with the IAAF Member Federation and the company/agency that conducts the background search, and will provide any additional information requested, if needed to complete the investigation of me.

3 3 ALL QUESTIONS MUST BE ANSWERED COMPLETELY If space provided is not sufficient, attach additional information on a separate sheet and clearly identify the item number the additional sheet(s) represents. 1) GENERAL a) Contact Information (Please provide in this space the information you would like USA Track & Field to use in contacting you.) Name: Address: City: State: Country: Postal Code: Telephone: Fax: b) Business Information (Please provide in this space the information that you would like for USA Track & Field to post on its Web site about you and your business.) Business Name: Address: City: State: Country: Postal Code: Telephone: Fax: Website: Business Motto: c) Personal Data Home Address: City: State: Country: Postal Code: Home Telephone: Social Security No.: Birthday: Birthplace: (MM/DD/YEAR) Citizenship: Passport No. Country of Issuance: Business Address: Business Telephone: Mobile Telephone: Fax: (Mandatory)

4 4 If you have resided elsewhere within the previous ten (10) years, please indicate as follows: Other Home Address: Postal Code: Other Home Address: Postal Code: d) Have you ever been known by any other name or surname? Yes No If yes, state all names used and when used (including, if you are a married woman, your maiden name): e) Have you made any previous applications for authorization as an IAAF Member Federation Athlete s Representative? Yes No If yes, please state all previous applications and set out the specifics of any refusals. f) Name of Partners and Business Associates and their respective role within your organization (specifically within in regards to athletes). g) Partners and Business Associates employers and addresses: h) Does your partner have any current business relationship with the IAAF Member Federation or with the IAAF or any of its Area Associations? Yes No If yes, specify in detail: 2) EDUCATION a) Law or Graduate School attended: School, City, Province/State, Country Dates of Attendance: from to (Month/Year) (Month/Year) Degree: Date Awarded: b) Colleges or Universities Attended: (Name) (City) (Dates Attended) (Degree) (Name) (City) (Dates Attended) (Degree) (Name) (City) (Dates Attended) (Degree) c) High School Attended: (Name) (City) (Dates) (Diploma -Y/N)

5 5 d) If you have not received a degree from an accredited four year college/university and a post-graduate degree from an accredited college/university, list below the negotiating experience you wish the IAAF Member Federation to consider in lieu of a college and postgraduate degree. This may include courses or seminars that you have taken that are relevant to work as an Authorized Athlete Representative, including topics such as contracts, contract negotiations or intellectual property. 3) EMPLOYMENT STATUS & BUSINESS STRUCTURE a) I am currently: (Check One) Employed by: (Name of Employer) (Address) (Telephone) (Dates of Employment) (Nature of Employment) Self-Employed: b) If self-employed, state the nature and location of your business: c) For the past ten (10) years state the names of your employers, their addresses, the positions you have held, and dates of your employment: d) For each business, firm or organization with which you are presently affiliated, identify the office (including address and telephone number) at which the business of representing professional Athletes is customarily conducted. If there is more than one location, designate the principal office:

6 6 e) For each such business, firm or organization, state whether it is a sole proprietorship, corporation, partnership, or other entity (specify): f) If such business is a partnership, state the name of each partner as hereinafter set out; if it is a corporation, state the name of each officer and members of the board of directors as hereinafter set out. For each of the aforesaid, identify those partners, associates, officers or members of the board of directors who are involved in athletics. g) Identify each person who (a) has a significant ownership interest in your firm or organization; (b) has wholly or partially financed your firm or organization (other than financing or credit extended in the ordinary course of business by lending institutions); or (c) directly or indirectly exercises or has the power to exercise a controlling influence over the management of your firm or organization: h) Describe fully the nature of each of your businesses, firm(s) or organization(s): i) With respect to your present business, list each person engaged in the representation of the Athlete(s) and their area of specialty, if any: 4) PROFESSIONAL REPRESENTATION EXPERIENCE (during the past 5 years) a) Please list below (or attach a list which includes) the names of every Athlete you are now representing or have represented in the past in individual contract negotiations, including the type of representations: CURRENT CLIENTS: Whom you will represent or for whom you have a valid contract during 2016.

7 FORMER CLIENTS 7 b) List the names of all Coaches, professional employees of any IAAF Member Federation, the IAAF, or Meeting Organizers that you are currently representing or that you have represented in the past five (5) years in individual contract negotiations related to Athletics: c) Apart from Athletics, list any other sports you currently represent or have previously represented any individuals, state whether you have been approved as an Athlete s Representative in such sport (and the date of approval) and for each such sport specify the number of Athletes you currently represent: d) Elaborate any further involvement in Athletics (personal athletic achievements, coaching, event organization experience, representing Athletes etc.): e) List any affiliation to governing bodies, particularly in relation to Athletics, including the organization of Athletics meetings:

8 8 f) Do you hold any official appointed or elected positions within the governing body of the IAAF Member Federation or the IAAF? Yes No If yes, please supply details: 5) SERVICES AND FEE ARRANGEMENTS a) What services do you or your firm provide to Athletes? (Place a check next to each service provided) Competition Participation Investment Counseling Contract Negotiation Estate Planning Litigation/Arbitration Tax Planning Financial Planning Appearances/Endorsements Other Services (explain) b) If you do not provide services in one or more of the above areas, do you make referrals or otherwise assist Athletes in securing such services? Yes No If so, describe what you do in this regard (include name and address of each individual/firm to which you customarily refer Athletes for each such service): Do you receive a commission or a fee for such referrals? Yes No If Yes, please describe: c) With respect to the areas in which you do not provide services, do you: (a) have an ownership interest in; (b) wholly or partially finance; or (c) directly or indirectly exercise a controlling influence over any firm or organization that does provide such services? If so, list the name and address of each firm or organization, the services it provides, and a detailed explanation of your relationship to and/or involvement with it (including financing relationships):

9 9 d) Do you have an agreement, understanding or referral relationship of any kind with any individual, firm or organization pursuant to which such individual, firm or organization solicits or encourages Athletes to use your services? Yes No If so, do you provide any compensation or other consideration to such individual, firm or organization? Yes No If so, explain fully, including the name and address of each person, firm or organization: e) Do you invest and/or manage money or assets (including funding) for your Athlete clients? Yes No If yes, you must be bonded in the amount equal to the assets you handle. Please provide below the details, amount of the bond, the name and address of surety or bonding company. As well please enclose a copy of same with your Application. Failure to do so will result in your Application being returned. f) Do you or any affiliated organizations or persons listed above receive any fees, commissions, rebates or other compensation other than as provided in the Standard Agreement as a result of: i) the Athlete s purchasing any securities or funds (stocks, bonds, mutual funds, real estate or other investments)? Yes No; ii) iii) the Athlete s purchasing any form of insurance (disability, life, casualty, etc.)? Yes No; the Athlete s making any endorsements, appearances or other licensing arrangements? Yes No. If so what is the basis of compensation received as a result of your representation of the Athlete in the above categories? Are these additional forms of compensation fully disclosed to the Athlete? Yes No in writing? Yes No Are these additional forms of compensation deducted from the fees you charge?

10 6) LAWYERS AND LAW GRADUATES 10 a) Name all jurisdictions and courts in which you are admitted to practice law. Include dates of admission, attorney registration number, and status (e.g. active, inactive, nonresident, suspended, etc.) Jurisdiction Date of Court Admission Attorney Registration Status b) Have you ever been denied admission to the practice of law in any jurisdiction (other than for failure of bar examination) or been denied access to the bar exam of any jurisdiction? Yes No If yes, provide a detailed explanation of the reason you were denied and the name of the jurisdiction in which you were denied. c) Provide the name, location and dates of admission of each bar to which you are, or have been admitted to practice: d) Do you have any Applications for Bar admission currently pending? Yes No If yes, please state where you have applied and the status of that Application: e) Have you ever been disbarred, suspended, reprimanded, censured, or otherwise disciplined or disqualified as an attorney, as a member of any other profession, or as a holder of any public office? Yes No If yes, please describe each such action, the dates of occurrence, and the name and address of the authority imposing the action in question:

11 11 f) Are any charges or complaints currently pending against you regarding your conduct as an attorney, as a member of any profession, or as a holder of public office? Yes No If yes, please indicate the nature of the charge or complaint and the name and address of the authority considering it: g) Has your right to practice before any governmental office, bureau, agency, commission, etc., ever been restricted, suspended, withdrawn, denied or terminated? Yes No If yes, please explain fully: 7) ALL APPLICANTS (Lawyers and law graduates need not repeat answers given in Section 6 pertaining to your status as a lawyer or law graduate when providing answers in this section. For example, if a lawyer is also a CPA, answer these questions only as they relate to your status as a CPA.) a) Are you a member of any business or professional organization which directly relates to your occupation or profession? Yes No If yes, please list: b) Please list any occupational certifications, professional licenses or other similar credentials (i.e., Certified Public Accountant, Chartered Life Underwriter, Registered Investment Advisor, etc.) you have obtained other than college or graduate school degrees, including dates obtained: c) Have you ever been denied an occupational certification or professional license, franchise or other similar credentials for which you applied? Yes No If yes, please explain fully:

12 12 d) Do you have currently pending any application for an occupational certification or professional license, franchise or other similar credentials? Yes No If yes, please describe and indicate the status of each such application: e) Have you ever been suspended, reprimanded, censured, or otherwise disciplined or disqualified as a member of any profession or as a holder of any public office? Yes No If yes, please describe each such action, the date(s) of occurrence, and the name and address of the authority imposing the action in question: f) Are any charges or complaints currently pending against you regarding your conduct as a member of any profession or as a holder of public office? Yes No If yes, please indicate the nature of the charge or complaint and the name and address of the authority considering it: g) Has your right to engage in any profession or occupation ever been disqualified, suspended, withdrawn, or terminated? Yes No If yes, please explain fully: h) Are you registered or have you applied to be registered by any country, territory, state or province which has promulgated statutes regulating Athlete s Representatives? Yes No If yes, list provinces and status of registration: i) Have you ever been convicted of or plead guilty to a criminal charge, other than minor traffic violations? Yes No If yes, please indicate nature of offense, date of conviction, criminal authority involved, and punishment assessed. It is necessary that you provide an official record of the criminal charge.

13 13 j) Have you ever been a defendant in any civil proceedings, including bankruptcy proceedings, in which allegations of fraud, misrepresentation, embezzlement, misappropriation of funds, conversion, breach of fiduciary duty, forgery, or legal malpractice were made against you? Yes No If yes, please describe fully and indicate results of the civil proceeding(s) in question: k) Have you ever had legal proceedings initiated against you by any Athlete s Association, Member Federation, Meeting Organizer or the IAAF for any reason? Yes No If yes, please describe fully and indicate the results of the civil action in question: l) Have you ever committed a violation of the IAAF Anti-Doping Rules, including those prohibiting assisting encouraging, aiding, abetting, covering-up or any other type of complicity involving an anti-doping rule violation or any attempted anti-doping rule violation? m) Have you ever been associated with, or have any knowledge of any betting activity by an Athlete? Yes No If yes, please describe: n) Have you ever initiated legal proceedings against any Athlete for any reason? Yes No If yes, please describe fully and indicate the results of the civil action in question: o) Have you ever had any legal proceedings initiated against you by any Athlete s Association, Member Federation, Meeting Organizer or IAAF for any reason, including with respect to violation of anti-doping rules or regulations? Yes No If yes, please describe fully and indicate the results of the legal or administrative action in question:

14 14 p) Have you ever been adjudicated insane or legally incompetent by any court? Yes No If yes, please provide details: q) Were you ever suspended or expelled from any college, university, or law school? Yes No If yes, please explain fully: r) Has any surety or any bond on which you were covered been required to pay any money on your behalf? Yes No If yes, please describe the circumstances: s) Are there any unsatisfied judgments of continuing effect against you (other than alimony or child support)? Yes No If yes, provide full details: 8) RELATIONSHIPS WITH OWNERS a) Do you, your corporation or any other business or related entity you have an interest in or anyone else in your firm or organization, have a proprietary interest in any professional sports team or in any meet organizing group? Yes No If so, describe fully: b) Are you now, or have you ever been, a partner or joint investor in any enterprise with a principal owner or officer of any professional sports team or in any meet organizing group? Yes No If so, describe fully:

15 15 c) Excluding Athletes, do you or anyone else in your firm or organization currently represent any partner, stockholder, management official, or other employee (including, but not limited to, Meeting Organizers or their employees, IAAF Member Federations or their employees, coaches, office personnel, or managers) associated with any IAAF Member Federation, IAAF Area Association or the IAAF in any capacity, for any purpose? Yes No If so, describe fully (subject to solicitor / client privilege) : d) If you are a lawyer do you or any member of your law firm, serve as counsel to an IAAF Member Federation, the IAAF, or any Meeting Organizer or affiliated entity? (subject to solicitor / client privilege). Yes No If so, describe fully: 9) REFERENCES a) Please list below the names, addresses and telephone numbers of at least three (3) persons, not related to you, who have known you for at least the last five (5) years and who can attest to your character. (Names of officers, authorized athletic representatives, or staff members of any IAAF Member Federation or the IAAF may not be used.) b) Please list below the names, current addresses, and current telephone numbers of at least two entities which can attest to your financial credit (e.g., credit card companies, lending institutions, etc.):

16 16 ACKNOWLEDGEMENT In submitting this Application for Authorization as a USA Track & Field Athlete Representative (the Application ) to the IAAF Member Federation, I hereby state that I understand, agree, affirm and acknowledge: 1. I have completely and accurately filled out the Application and I will update and supplement the information provided in the Application (including an updated list of those Athletes whom I currently represent) as requested, or at least annually; and I will provide a copy of this Application, as well as any update or supplement to the Athletes I represent, or will represent in the future; and 2. I have not made any material misrepresentation or any false or misleading statements of a material nature in answering any questions on the Application, and, if the IAAF Member Federation should determine I have done so, such determination may constitute grounds for denial, suspension, withdrawal or revocation of an IAAF Member Federation Authorization as an Athlete s Representative; and 3. The information contained in the Application is designed to assist the IAAF Member Federation member, both present and future, in making informed selections of Athlete s Representatives. The personal data contained in this Application will be processed, stored and used by the IAAF Member Federation to the extent necessary and permitted by and in accordance with the applicable privacy and data protection laws. The personal data contained in this Application can be transferred in the sole discretion of the IAAF Member Federation to the IAAF or another IAAF Member Federation to whom the Athlete s Representative has applied for authorization or recognition and it may be used by the IAAF or the said IAAF Member Federations as they deem appropriate in the performance of their functions, provided that the IAAF or such other IAAF Member Federations comply with privacy and data protection laws applicable to them. 4. I hereby, to the extent permitted by the applicable law, give my permission to the IAAF Member Federation and the IAAF to: a. List my name, address, phone number, and other pertinent private or personal information included under the Athlete s Representatives section on the IAAF Member Federation web site, and any other web site which the IAAF Member Federation designates, including the IAAF; b. Provide the IAAF head office and all Athletes with the information referred to herein for distribution; and c. Distribute the information referred to herein as required. I waive, to the extent permitted by the applicable law, any rights I might have had, now have or may have in the future, with respect to any private or personal information referred to in paragraph 4 above and hereby release the IAAF Member Federation and the IAAF from any claims under any privacy or other legislation with respect to the aforesaid private or personal information. I, _, being first sworn, declare and affirm under penalty of perjury that I have read the foregoing questions in the within Application and have personally answered the same fully and honestly and the answers to said questions are true and correct to the best of my knowledge, information and belief. Further, I agree to be bound by Regulation 25, the USATF Code of Ethics, the USATF SafeSport Handbook and the USATF Agent Code of Conduct, in their entirety. Signature of Applicant Date

17 17 USA Track & Field Authorized Athlete Representatives will receive the following benefits: Coverage under the USATF Professional Liability Errors and Omissions for the performance of providing AR services to USATF athletes ($30k each/$2m agg., which fulfills the IAAF requirement). Access to USATF s Competition Rules and Elite Athlete Handbook Access to USATF s quarterly Athlete Representative Newsletter USATF Authorized Athlete Representative ID card Annual USATF membership Listing in USATF s Media Guide and Elite Athlete Handbook USA Indoor Championships Credential, heat sheets and results, shuttle bus access USA Outdoor Championships (or, if applicable, Olympic Trials) Credential, heat sheets and results, shuttle bus access Other mailings, as applicable Please return this form (signed and dated) along with the completed forms noted below and payment in the amount of $800 in the form of a check or money order credit card payable to USA Track & Field. For credit card payments, please click on the following link and complete the form If there are any issues please contact Sarah Gilfoy via phone ( ). Upon completion of the attached application, please also complete the forms noted below: If you are a U.S. resident, please complete and submit the attached W9 form. If you are a foreign resident, please complete and submit the attached W-8IMY form. If you have a Top 30 Athlete, please complete and submit the attached Registration of an Authorised Athlete s Representative form.

18 REGISTRATION OF AN AUTHORISED ATHLETE S REPRESENTATIVE APPENDIX 4 (In accordance with the AR Regulations) - PLEASE COMPLETE IN CAPITAL LETTERS Athlete s Representative IAAF Member Federation The IAAF Member Federation relying upon the Application filed hereby issues the registration of the Athlete s Representative with the Member Federation as an Athlete s Representative pursuant to the AR Regulations as amended from time to time hereafter. This registration is effective the beginning as of the date hereof and shall continue in full force and effect and until and unless suspended, withdrawn, revoked or terminated in accordance with the AR Regulations until December 31, 20. With respect to the following Athletes: MEN Name DoB Event Name DoB Event WOMEN Name DoB Event Name DoB Event Signature of the Athlete s Representative Signature of the President or General Secretary (with stamp) Dated at the City of, in the Country of, this day of, 20. NOTE: This registration to be completed upon Authorisation of the Athlete s Representative in accordance with the AR Regulations. AR Regulations as in force from 1 st May 2011

19 Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven 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) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 5 Address (number, street, and apt. or suite no.) 6 City, state, and ZIP code 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) Requester s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. 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 2. 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 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Date Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No X Form W-9 (Rev )

20 Form W-9 (Rev ) Page 2 Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien; A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; An estate (other than a foreign estate); or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States: In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called backup withholding. Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships above. What is FATCA reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or doing business as (DBA) name on line 2. c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a disregarded entity. See Regulations section (c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, Business name/disregarded entity name. If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

21 Form W-9 (Rev ) Page 3 Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2. Line 3 Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3. Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the Limited Liability Company box and enter P in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the Limited Liability Company box and in the space provided enter C for C corporation or S for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the Limited Liability Company box; instead check the first box in line 3 Individual/sole proprietor or single-member LLC. Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you. Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 1 An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2) 2 The United States or any of its agencies or instrumentalities 3 A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities 4 A foreign government or any of its political subdivisions, agencies, or instrumentalities 5 A corporation 6 A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession 7 A futures commission merchant registered with the Commodity Futures Trading Commission 8 A real estate investment trust 9 An entity registered at all times during the tax year under the Investment Company Act of A common trust fund operated by a bank under section 584(a) 11 A financial institution 12 A middleman known in the investment community as a nominee or custodian 13 A trust exempt from tax under section 664 or described in section 4947 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for... THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to Barter exchange transactions and patronage dividends Payments over $600 required to be reported and direct sales over $5,000 1 Payments made in settlement of payment card or third party network transactions Exempt payees 1 through 4 Generally, exempt payees 1 through 5 2 Exempt payees 1 through 4 1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with Not Applicable (or any similar indication) written or printed on the line for a FATCA exemption code. A An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B The United States or any of its agencies or instrumentalities C A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section (c)(1)(i) E A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section (c)(1)(i) F A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G A real estate investment trust H A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I A common trust fund as defined in section 584(a) J A bank as defined in section 581 K A broker L A trust exempt from tax under section 664 or described in section 4947(a)(1) M A tax exempt trust under a section 403(b) plan or section 457(g) plan Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner s SSN (or EIN, if the owner has one). Do not enter the disregarded entity s EIN. If the LLC is classified as a corporation or partnership, enter the entity s EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at You may also get this form by calling Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling TAX-FORM ( ). If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write Applied For in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note. Entering Applied For means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.