Application Form Altus Global Gold Limited

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1 Application Form Altus Global Gold Limited Please ensure you read the Company s current Offering Memorandum before you complete this Application Form. If you have any queries about the information contained within this Application Form or the Offering Memorandum you should consult a professional investment advisor or independent financial advisor. The Application Form is current as at the date of publication but is subject to change. QUALIFIED INVESTOR You must confirm your status as a Qualified Investor as defined in the Offering Memorandum and you might be asked to provided documentary evidence to confirm your standing as a Qualified Investor. SUBSCRIPTION PROCESS Please complete and return the following documents to the Administrator (contact details below): 1. Signed and completed Subscription document 2. Signed and completed Investor Declaration Form 3. Due Diligence Documents as applicable 4. Remit monies to account detailed in Section 4 REDEMPTION PROCESS Please complete and return the signed and completed Redemption Instructions to the Administrator. Note the Directors are entitled to restrict the value of Shares in the Company redeemed on any Dealing Day to 25% of Net Asset Value. Accordingly, on certain Dealing Days the Directors may not permit the redemption of such Shares or may limit the number of Shares which may be redeemed. Further details are provided in the Offering Memorandum. ADMINISTRATOR Physical Address for post requiring a signature: Mailing Address: Praxis Fund Services Limited Praxis Fund Services Limited Sarnia House P O Box 296 Le Truchot St Peter Port St Peter Port Guernsey Guernsey GY1 4NA GY1 4NA Enquiries: Tel: +44 (0) Fax: +44 (0) Info@pfs.gg Page 1 of 15

2 Section 1 To be completed by Individual Investors All Individuals Investors to complete this page in BLOCK CAPITALS REGISTERED NAME Shares will be registered exactly in accordance with the Registered Name given above. REGISTRATION DETAILS FIRST APPLICANT JOINT APPLICANT (if applicable) TITLE (MR/MRS/MISS) SURNAME FORENAMES ANY PREVIOUS NAMES DATE & PLACE OF BIRTH NATIONALITY CURRENT RESIDENTIAL ADDRESS (PO Box only address is not sufficient) RESIDENTIAL COUNTRY RESIDENTIAL POST CODE SOURCE OF FUNDS (please state the economic activity that generated the funds being used for investment. One word answers such as inheritance need to be expanded upon) OCCUPATION CORRESPONDENCE DETAILS CORRESPONDENCE ADDRESS CORRESPONDENCE COUNTRY CORRESPONDENCE POST CODE DAYTIME TEL No FAX No FIRST APPLICANT JOINT APPLICANT (if applicable) Please note that all correspondence will be sent to the first applicant unless specific alternative instructions are received. If there are more than two applicants please re print this page and enclose with the Subscription Documents. Page 2 of 15

3 Section 2 To be completed by Entities (Corporate/Trusts & Partnerships) All Entities to complete this page in BLOCK CAPITALS REGISTERED NAME Shares will be registered exactly in accordance with the Registered Name given above REGISTRATION DETAILS NAME OF ENTITY ACCOUNT DESIGNATION (IF APPLICABLE) REGISTERED OFFICE ADDRESS CORRESPONDENCE ADDRESS (IF DIFFERENT FROM THE REGISTERED ADDRESS) ADDRESS (PO Box only address is insufficient) COUNTRY POST CODE COUNTRY OF REGISTRATION REGISTRATION NUMBER DATE OF REGISTRATION STATEMENT OF ENTITY S ACTIVITY PRIMARY CONTACT DETAILS SECONDARY CONTACT DETAILS NAME TEL No FAX No Page 3 of 15

4 Section 3 To be completed by Trusts All Trusts to complete this page in BLOCK CAPITALS DETAILS OF TRUST NAME AND DATE OF ESTABLISHMENT OF TRUST SOURCE OF TRUST FUNDS DETAILS OF SETTLOR AND PROTECTOR SETTLOR PROTECTOR FULL NAME NATIONALITY DATE & PLACE OF BIRTH CURRENT RESIDENTIAL ADDRESS (PO Box only address is insufficient) POST CODE DETAILS OF TRUSTEES TRUSTEE TRUSTEE FULL NAME OF TRUSTEE NATIONALITY DATE & PLACE OF BIRTH CURRENT RESIDENTIAL ADDRESS (PO Box only address is insufficient) POST CODE DETAILS OF BENEFICIARIES FULL NAME OF BENEFICIARY NATIONALITY DATE & PLACE OF BIRTH CURENT RESIDENTIAL ADDRESS (PO Box only address is insufficient) POST CODE BENEFICIARY BENEFICIARY If there is not enough space on this form please attached additional documents to identity all the Trust parties Page 4 of 15

5 Section 4 Payments & Authorised Signatories I/We the undersigned having received and read a copy of the Fund Documents of Altus Global Gold Limited hereby apply to subscribe for Shares in Altus Global Gold Limited and undertake to have settled funds by telegraphic transfer, for value by the close of business 3 days before the relevant Dealing Day (normally the first business day of each calendar month). Late applications may not be accepted. I/we wish to invest the following Sterling amount in the Fund The initial minimum subscription amount is 20,000 (Twenty thousand Pounds Sterling) subject to satisfying the Qualifying Investor criteria if less than USD100,000 equivalent. ROUTING INSTRUCTIONS FOR THE FUND SUBCRIPTIONS ACCOUNT FOR STERLING PAYMENTS ORIGINATING FROM THE UNITED KINGDOM CHAPS SORT CODE SWIFT CODE ACOUNT NAME ROYCGGSP Royal Bank of Canada (Channel Islands) Limited ACCOUNT IBAN FOR FURTHER CREDIT TO BENEFICIARY ACCOUNT GB33ROYC PFS RE ALTUS CLIENT BENEFICIARY ACCOUNT NUMBER FOR STERLING PAYMENTS ORIGINATING FROM OUTSIDE THE UNITED KINGDOM CORRESPONDENT BANK NAME CORRESPONDENT SWIFT ACCOUNT NAME NatWest, London, United Kingdom NWBKGB2L Royal Bank of Canada (Channel Islands) Limited ACCOUNT NUMBER ACCOUNT SWIFT CODE ROYCGGSP ACCOUNT IBAN FOR FURTHER CREDIT TO BENEFICIARY ACCOUNT NAME GB33ROYC PFS RE ALTUS CLIENT IBAN / ACCOUNT NUMBER INVESTORS BANK ACCOUNT DETAILS Please note that additional information will be requested if monies are being transferred from an account held other than in the name of the Applicant BANK NAME SORT / SWIFT CODE BANK ADDRESS ACCOUNT NAME IBAN / ACCOUNT NUMBER Page 5 of 15

6 Section 4 Payments & Authorised Signatories SIGNING INSTRUCTIONS All Authorised Signatories to Sign Any Authorised Signatories to Sign To Sign in accordance with the attached Authorised Signatory List Please tick as appropriate AUTHORISED SIGNATORIES NAME (BLOCK CAPITALS) The following individuals are authorised to give instructions on the account in accordance with the Signing Instructions SIGNATURE Page 6 of 15

7 Professional Investors Section 5 - Investor Declaration Form INVESTOR DECLARATION FORM This section must be completed by ALL applicants to confirm that they are not a US Person. A US Person has the meaning given to it in Rule 902 of Regulation S under the US Securities Act of 1933, as amended. I/We hereby confirm that I/we are not a US Person This section must be completed by ALL applicants to confirm their status as a Qualifying Investor. The QIF Guidance defines a Qualifying Investor as meaning a Professional Investor, an Experienced Investor and/or a Knowledgeable Employee each such term as defined below. Investors will therefore need to meet the criteria of at least one of these definitions. EITHER If the Investment is being made directly by the Investor (not through an authorised agent) : :; Tick OR If the Investment is NOT being made directly by the Investor BUT through an authorised agent: Tick I hereby confirm that I am eligible to be treated as a Qualifying Investor, since I satisfy the definition thereof in light of the positive responses that I have given to the questions below. I certify that I have read and understood the Fund Documents including the mandatory risk warnings. I hereby confirm that I have been properly appointed as an authorised agent of a prospective investor in the Scheme described above. I certify that my principal is eligible to be treated as a Qualifying Investor, since they satisfy the definition thereof in light of the positive responses that I have given to the questions below. I certify that my principal has read and understood the Fund Documents including the mandatory risk warnings. I qualify as a Professional Investor as I am (one or more of the following): OR my principal qualifies as a Professional Investor as he/she is (one or more of the following) and I/we can provide documentary evidence as to my standing as a Qualified Investor. Please Tick I am: (i) a Government, local authority, public authority or supranational body (in the Bailiwick of Guernsey or elsewhere); or (ii) a person, partnership or other unincorporated association or body corporate, (whether incorporated, listed or regulated in an OECD country or otherwise) whose ordinary business or professional activity includes or it is reasonable to expect that it includes, acquiring, underwriting, managing, holding or disposing of investments whether as principal or agent, or the giving of advice on investments; or (iii) an affiliate of the Company or an associate of an affiliate of the Company. (The terms affiliate and associate of an affiliate mean financial services businesses or financial services professionals associated, directly or indirectly, with the operation of the Company); or (iv) an individual investor who makes an initial investment of not less than US$100,000 or equivalent in the Company. Provided that the initial test has been met, subsequent investments by the same investor may be of lower amounts. Page 7 of 15

8 Knowledgeable Employee Experienced Investors Section 5 - Investor Declaration Form I qualify as an Experienced Investor as I am OR my principal qualifies as a Experienced Investor as he/she is: a person, partnership, or other unincorporated association or body corporate which has in any period of 12 months (whether on his own behalf or in the course of his employment by another person) so frequently entered into transactions of a particular type in connection with open-ended and closed-ended collective investment schemes; and/or general securities and derivatives as defined in Schedule 1 of the Protection of Investors (Bailiwick of Guernsey) Law, 1987, as amended (in summary, that definition includes equities, bonds, participations in closed-end investment vehicles, warrants, options, futures, contracts for differences and rights on any of those investments) being transactions of substantial size entered into with, or through the agency of, reputable persons who carry on investment business, that he can reasonably be expected to understand the nature of, and the risks involved in, transactions of that description; or who provides a certificate from an appropriately qualified investment advisor confirming that the investor has obtained independent advice. I/we can provide documentary evidence as to my/our standing as a Qualified Investor. Please Tick I qualify as an Knowledgeable Employee as I am (one or more of the following): OR my principal qualifies as a Knowledgeable Employee as he/she is (one or more of the following) and I/we can provide documentary evidence as to my standing as a Qualified Investor. I am: Please Tick (i) (ii) a person who is (or has been within a period of three years up to the date of application for investment in the Company) an employee, director, general partner, consultant or shareholder of, or to, an affiliate appointed by the Qualifying Investor Company to advise, manage or administer the investment activities of the Company, who is acquiring an investment in the Company as part of his remuneration or an incentive arrangement or by way of co-investment, either directly or indirectly through a personal investment vehicle, such as a trust, for or substantially for, that person; or an employee, director, partner or consultant to or of any person referred to at (ii) of the Professional Investor section on previous page or anyone who has fulfilled such a role in respect of any person referred to at (ii) of the Professional Investor Section on the previous page within a period of three years up to the date of application for investment in the Company. The term employee relates only to persons who are, or have been employed in a relevant role and would not extend to clerical, secretarial or administrative roles. DECLARATION SIGNATURE(S) Title/Capacity in which Signed Authorised Signature(s) Date Page 8 of 15

9 Section 3 Professional Intermediaries Section 2 Corporate Investors Section 1 Individual Investors Section 6 Customer Due Diligence Documentation In order to comply with regulations for the avoidance of money laundering ALL applicants must be identified and verified by the Administrator and the Company. Where due diligence documents have already been supplied to the Administrator please indicate clearly: Fund Name Registered Name Alternatively, the identification and verification evidence required is detailed below. ONE of the following sections will apply and the documents detailed will need to be supplied to the Administrator. Notes at the end of the section should be used when completing this section of the Application Form. Special consideration needs to be given to the correct certification of the required documents. Certified true copy of Passport / ID Card * Certified true copy of a recent Utility Bill or Bank Statement confirming residential address * [Utility bills must be less than three months old when received by the Administrator and mobile phone bills are not deemed acceptable form of verification] Please confirm source of wealth * Please note that all individual investors applying jointly must provide the required documentation for each individual. Structure chart showing all related parties Certified true copy of the Certificate of Incorporation (and certificate of change of name, where applicable). Certified true copy of the Memorandum and Articles of Association Certified true copy of the Authorised Signatory List. [Each Individual on whose instructions or requests we will be expected to act must also produce all the due diligence documents specified for Individual Investors] List of all Directors and Company Secretary with full name and specimen signatures [Each Individual on the list must also produce all the documents specified for Individual Investors ] Please enclose an certified true copy of the Shareholders Register signed by the Director(s) or Company Secretary [Each beneficial owner who directly or indirectly holds 25% or more of the issued share capital must also produce all the documents specified for Individual Investors or if an entity produce documents as per Corporate Investors or Trust, Nominees and Fiduciary clients section] Please confirm source of wealth Under certain circumstances, Professional Intermediaries can be treated as a Principal and customer due diligence is required on the Principal rather than on the Intermediary s customers. Professional Intermediaries must be a financial services business from a recognised jurisdiction but not a trust or corporate service provider. This category should be used where the Principal invests the customers money on a discretionary or advisory capacity, is the sole operator of and retains ultimate effective control over the account. Disclosure of the Regulatory Body together with the company regulation number. Professional Intermediary Letter (refer to section 9 for a sample letter) Official certified copy of the Authorised Signatory List Page 9 of 15

10 Section 7 General Introduction Certificate Section 6 Partnership Section 5 Listed Company Section 4 Trusts, Nominees & Fiduciary clients Section 6 Customer Due Diligence Documentation Structure chart showing all trust parties Certified True copy of an Extract of the Trust deed and any supplemental deeds of amendment confirming the date, place and establishment of the Trust and all the parties to the Trust i.e. Trustees /Beneficiaries/ Principal/ Settlor/ Protector also including and the signatures / seal pages. [Each Individual Trustee must provide all the documents specified for Individual Investors or if a Corporate Trustee provide documents as per the Corporate Investors section] Full names and specimen signature for each individual trustee, or if a Corporate Trustee, any individual on whose instructions or request we are expected to act [Each Individual on the list must also produce all the documents indicated in the Individual Investors section, unless the Company is an Appendix C regulated financial services business*] Written confirmation from the Trustee of all Beneficiaries/ Settlor/ Principal/ Protector of the Trust. The Trustee must provide details of each beneficiary(s)/ Settlor/ Principal/ Protector full name, residential address, date of birth, place of birth, nationality and passport number. If any of the beneficiaries are minors please specify their place of residence and identify their family members with whom they reside. Please confirm source of wealth * for the current list of Appendix C Jurisdictions please contact the Administrator; Evidence that the Company is listed on a recognised Stock Exchange Full names and specimen signatures of any individuals from the investing company on whose instructions or requests we might be expected to act. [Each Individual listed must also produce all the documents indicated in the Individual Investors section] Please note that the Company needs to be listed on a Recognised Stock Exchange Please confirm source of wealth Structure chart showing all related parties Certified true copy of the Partnership Certificate/Agreement identifying the General/Limited Partners Full names and specimen signature on any individual from the Partnership on whose instructions or request we are expected to act [Each Individual listed must also produce all the documents specified for Individual Investors ] List of all Partners names with specimen signatures [Each Individual listed must also produce all the documents indicated in the Individual Investors section. Where partners are not individuals, the applicable legal body or legal arrangement requirements will apply] Please confirm source of wealth Under certain circumstances an Appendix C regulated Financial Services Business or IFA can be treated as introducer to the administrator. The introducer must hold all the client due diligence and be prepared to supply this to the administrator on demand. The Administrator may place reliance on an Appendix C FSB or IFA to have verified the identity of the customer, beneficial owners and any underlying principals. The introducer must provide a written confirmation that it applies appropriate CDD processes, in the form of an Introducer Certificate. Disclosure of the Regulatory Body together with the company regulation number. Completed General Introduction certificate (available from the Administrator on request) Official certified copy of the Authorised Signatory List Page 10 of 15

11 Section 6 Customer Due Diligence Documentation Notes for the Completion of Identification of Applicants under anti-money laundering regulations *PLEASE NOTE that certified copies of documents can only be accepted if they comply with the below. If they do not comply the Administrator cannot be reliable for any delays incurred with the application. Certification must be by one of the following ( Certifiers ): An embassy, consulate or high commission of the country of issue of documentary evidence of identity; A member of the judiciary, a senior civil servant, or a serving police or customs officer; A lawyer, notary public; actuary; accountant who is a member of a recognised professional body, a member of the Institute of Chartered Secretaries and Administrators; or A director, officer or manager of a regulated financial services business operating in an equivalent jurisdiction to Guernsey. Please note that countries that fall within the term equivalent jurisdiction may vary, from time to time, if you require updated information in this regard, please contact the Administrator. The Certifier must have seen the original document and photocopy. The Certifier will compare the documents and must write the following words on the photocopy: For photographic ID Certified a True Copy of the original document, which I have seen, and that the photograph shown is a true likeness of the person named therein, who I have met. For other ID Certified a True Copy of the original document, which I have seen. The Certifier must sign and record in block capitals his/her full name, the capacity in which he/ she is signing, any professional membership number, their contact details and the date of certification. It some circumstances certified true translations of documents not in the English language will be required. The Certifier must sign and record in block capitals his/her full name, the capacity in which he/ she is signing and the date of translation. Page 11 of 15

12 Section 7 Investor Declarations I/We confirm that I am/we are 18 years of age or over, aware of the risks involved in investing in the Company, and as a Qualifying Investor (as defined in the Offering Memorandum) and am/are not acquiring Shares as a nominee for, a person who is not an Qualifying Investor nor do I/we intend selling or transferring any Shares which I/we may purchase to any person who is not an Qualifying Investor. I/We will not offer, sell or deliver any of such Shares in the Fund directly or indirectly to a US Person or a person who is not a Qualified Investor (as defined in the Offering Memorandum). I/We agree to provide these confirmations to the Administrator and the Company at such times as the Administrator/Company may request, and to provide on request such certifications, documents or other evidence as the Administrator/Company may reasonably require to substantiate such representations. I/We agree to notify the Company immediately if I/we become aware that any of the confirmations are no longer accurate and complete in all respects and agree immediately either to sell or to tender to the Company for redemption a sufficient number of Shares to allow the confirmation to be made. I/We having received, understood and considered a copy of the Offering Memorandum and hereby confirm that this application is based solely on the Offering Memorandum for the Company current at the date of this subscription and the material contracts therein referred together (where applicable) and that I/we are not relying on any representations made by placement agents or other third parties. The Administrator and the Company are each hereby authorised and instructed to accept and execute any instructions in respect of the Shares to which this application relates given by me/us in written form by mail or by /facsimile. If the instructions are given by me/us by /facsimile, I/we undertake to confirm them in writing by mail. I/We hereby agree to indemnify each of the Administrator and the Company and agree to keep each of them indemnified against any loss of any nature whatsoever arising to any of them as a result of any of them acting upon /facsimile instructions. The Administrator and the Company may rely conclusively upon and shall incur no liability in respect of any action taken upon any notice, consent, request, instruction or other instrument believed in good faith to be genuine or to be signed by properly authorised persons. I/We acknowledge that due to anti-money laundering requirements the Company/Administrator may require additional documents and information before the application can be processed and the Administrator and Company shall hereby be held harmless and indemnified by the undersigned against any loss arising as a result of a failure to process the application if such information has not been supplied. I/We acknowledge that the Company may compulsorily redeem my/our Investor Shares in certain circumstances as laid down in the Offering Memorandum I/We, agree to indemnify and hold harmless the Administrator and Company against any loss, liability, cost or expense (including without limitation attorneys fees, taxes and penalties) which may result directly or indirectly, from any misrepresentation or breach of any warranty, condition, covenant or agreement set forth herein or in the Investor Declaration Form attached herewith or in any other document delivered by the undersigned to the Administrator/Company. I/We warrant that I/We am/are a Qualified Investor, and should be categorised as either a Professional Investor, Eligible Investor or Experienced Investor (as defined in the Offering Memorandum) and that I/We have the knowledge, expertise and experience in financial matters to evaluate the risks of investing in the Fund, and I/We am/are aware of the risk inherent in investing in the Fund. I/We acknowledge that an investment in the Company involves special risks that could lead to a loss of all or a substantial portion of any investment made. Page 12 of 15

13 Section 7 Investor Declarations By signing below: (a) I/We confirm that the application is made on the terms and conditions set out in the Application Documents. (b) I/We certify the above information to be true and correct and that I/We will supply the required information with my/our application (all applicants to sign). FIRST SIGNATORY Title/Capacity in which Signed Authorised Signature(s) Date SECOND SIGNATORY Title/Capacity in which Signed Authorised Signature(s) Date NOTES: Note 1: Applications must be received by Praxis Fund Services Limited. Note 2: To be valid, the Application Form must be signed by each applicant if there is more than one applicant. In the case of a partnership, subscriptions should be in the name(s) of and signed by all the partners. Note 3: If this Application Form is signed under a power of attorney, such power of attorney or a duly certified copy thereof must accompany this Application Form. Note 4: Measures aimed towards prevention of money laundering will require a subscriber to verify their identity. This obligation is absolute but may vary in accordance with the applicable criteria set by the Guernsey Financial Services Commission from time to time in accordance with the Prevention of Money Laundering Act regarding (1) applications being made via a recognised financial intermediary, or (2) payment made through a banking institution in a country with comparable safeguards against money laundering to those in the Bailiwick of Guernsey. Shares will not be allocated to any application not including the required anti-money laundering documentation. Note 5: If this form is not fully completed to the satisfaction of the Administrator and the Company, the Application may not be accepted. Page 13 of 15

14 Address Contact Section 8 Redemption Instruction REGISTERED HOLDER TO : Praxis Fund Services Ltd Tel Fax Web Redemption of Shares ("Shares") EITHER At the next Redemption Day, please redeem sufficient Shares to realise the following amount Sterling OR At the next Redemption Day, please redeem the following number of Shares Shares Payment of Redemption Proceeds Redemption proceeds will only be paid when this redemption instruction is received in original form by Praxis Fund Services Limited EITHER Please pay the redemption proceeds to the bank account designated on the original Application Form: OR Please pay the redemption proceeds to the following bank account: Please Tick BANK NAME In the event of the Applicant wishing the redemption proceeds to be paid to a bank account differing from that designated on the Application Form, the Applicant should submit with this form sufficient evidence to satisfy the Administrator that the change in the designated bank account is duly authorised and otherwise lawful and valid. SORT/ SWIFT CODE BANK ADDRESS ACCOUNT NAME IBAN / ACCOUNT NUMBER FIRST SIGNATORY Title/Capacity in which Signed Authorised Signature Date Name In BLOCK CAPITALS : SECOND SIGNATORY Title/Capacity in which Signed Authorised Signature Date Name In BLOCK CAPITALS : Page 14 of 15

15 Section 9 Professional Intermediary Letter All Professional Intermediaries need to supply the following letter addressed to Praxis Fund Services Limited on their own headed paper and signed by authorised signatories of the regulated entity (electronic copies of this letter are available from the Administrator on request). Dear Sir Registered Name Specify Country or Jurisdiction where Regulated Specify Name of Regulatory Authority We understand that in accordance with Guernsey legislation, in order to treat us as the client principal, you require us to give the following confirmations to Praxis Fund Services Limited: 1. that we are a regulated financial services business from an Appendix C Jurisdiction*, other than a trust and corporate service provider; OR 2. that we are a wholly owned subsidiary of a regulated financial services business (as described in 1 above) offering nominee or pensioner trustee services to our regulated parent company for no charge; OR 3. a person licensed under the Regulation of Fiduciaries, Administration Businesses and Company Directors, etc (Baliwick of Guernsey) Law 2000; AND 4. we hereby provide this written confirmation to Praxis Fund Services Limited that: 1. we, the Professional Intermediary, have appropriate risk-grading procedures in place to differentiate between the Customer Due Diligence ( CDD ) requirements for high and low risk relationships; 2. we conduct all necessary CDD procedures in respect of our customers, including enhanced CDD measures for PEP and other high risk relationships; 3. the account will only be operated by ourselves and that we have ultimate, effective control over the account. 5. we confirm that the purpose and nature of the business relationship between ourselves, the Professional Intermediary, and our client(s) is: FIRST SIGNATORY Title/Capacity in which Signed Authorised Signature** Date Name In BLOCK CAPITALS : SECOND SIGNATORY Title/Capacity in which Signed Authorised Signature** Date Name In BLOCK CAPITALS : * for the current list of Appendix C Jurisdictions please contact the Administrator; ** please ensure that this letter is signed by valid authorised signatories and a certified true copy of the relevant authorised signatory list is enclosed. Page 15 of 15

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