Beneficial Owners Certification Form

Beneficial Owners Certification Form

This Beneficial Owners Certification Form (the Certification) is made and entered into as of the date of signature below by and between Reporting Company: , organized under jurisdiction: , with principal address: and Certifying Individual: , title or capacity: , with address: .

Recitals

WHEREAS, the Reporting Company seeks to comply with applicable customer due diligence and anti-money laundering obligations and requires disclosure of the identity of its beneficial owners and individuals exercising substantial control; and

WHEREAS, the Certifying Individual is authorized to provide and certify information on behalf of the Reporting Company and to attest to the identity of each beneficial owner and controlling person identified herein; and

WHEREAS, the parties desire to record the identity, form of control, and relevant identifying information for each person who is a beneficial owner or exercising substantial control of the Reporting Company.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. Definitions

1.1 Beneficial Owner means, with respect to the Reporting Company, any individual who directly or indirectly, whether through ownership, agreement, arrangement, relationship or otherwise: (a) exercises substantial control over the entity; or (b) owns or controls twenty-five percent (25%) or more of the ownership interests of the entity. For purposes of this Certification, Beneficial Owner also includes any individual identified by law or regulation as required to be reported to the Recipient Institution.

1.2 Substantial Control means an individual who holds a senior officer position, has authority to appoint or remove a plurality of the governing body, directs important decisions of the entity, or otherwise performs similar functions as defined by applicable regulatory standards.

2. Beneficial Owners Disclosure

The Certifying Individual hereby identifies the following individuals as Beneficial Owners or persons exercising Substantial Control of the Reporting Company. The Certifier represents that the information supplied for each person is true, correct and complete to the best of the Certifier's knowledge.

Beneficial Owner 1

Date of Birth: — Tax Identifier (last 4 digits of SSN or foreign TIN): — Ownership/Control Basis:

Beneficial Owner 2

Date of Birth: — Tax Identifier (last 4 digits): — Ownership/Control Basis:

Beneficial Owner 3 (if applicable)

Date of Birth: — Tax Identifier (last 4 digits): — Ownership/Control Basis:

If there are additional Beneficial Owners, attach a signed, dated schedule that provides the same information as above for each additional individual. The Certifier declares:

No individual exercises ownership of 25% or more and no individual otherwise meets the definition of Beneficial Owner; or

Ownership is held by a trust or other legal arrangement; the controlling individual(s) and settlor(s)/trustees are identified in the attached schedule.

3. Certifications and Representations

The Certifying Individual hereby certifies, represents and warrants to the Reporting Company and any recipient institution relying on this Certification that:

(a) The information provided in Section 2 and any attached schedule is true, correct and complete as of the date of signature; the Certifier has made reasonable inquiries to verify the identity of each individual identified as a Beneficial Owner or person exercising Substantial Control; and the identity documents and records relied upon accurately correspond to the persons identified.

(b) The Certifying Individual is authorized to provide this Certification on behalf of the Reporting Company and to make the representations and warranties contained herein, and acknowledges that the Reporting Company and recipient institutions may rely upon such authority in fulfilling legal and regulatory obligations.

(c) The Certifier will notify the Reporting Company and any institution that relies on this Certification of any material change in the information provided within ten (10) business days of learning of such change and will provide updated, accurate information and documentation.

4. Recordkeeping, Use and Consent

The Certifier acknowledges that the Reporting Company and any recipient financial institution may retain records of this Certification, and may use, store and disclose the information to comply with applicable laws, regulations and to respond to lawful requests from governmental authorities. The Certifier consents to such use and disclosure for compliance and enforcement purposes.

5. Indemnification

The Reporting Company agrees to defend, indemnify and hold harmless any recipient institution and its officers, directors and employees from and against any and all claims, liabilities, costs and expenses (including reasonable attorneys' fees) arising out of or relating to any material misrepresentation, omission, or inaccurate information provided in this Certification or in any schedule attached hereto.

6. Notices

All notices required or permitted under this Certification shall be in writing and delivered to the addresses provided in the opening paragraph or to such other address as a party designates by written notice. Notices shall be effective upon receipt.

7. Amendments; Waiver; Counterparts

Any amendment or modification of this Certification must be in writing and signed by an authorized representative of each party. No waiver of any term or breach shall be effective unless in writing and signed by the party waiving compliance. This Certification may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

8. Governing Law

This Certification shall be governed by and construed in accordance with the laws of the jurisdiction of formation of the Reporting Company, without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the courts of that jurisdiction for any dispute arising out of or relating to this Certification.

9. Entire Agreement

This Certification, including any attached schedules, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings, whether oral or written, concerning such subject matter.

10. Severability

If any provision of this Certification is determined to be invalid, void or unenforceable, such determination shall not affect the remaining provisions, which shall remain in full force and effect and be interpreted so as to give maximum effect to the original intent of the parties.

Acknowledgment and Signature

The undersigned Certifying Individual hereby certifies under penalty of perjury that the information provided in this Certification and any attachments is true, correct and complete, and that the Certifier is authorized to provide such information on behalf of the Reporting Company.

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