Broadridge Legal Transfer Form – Fill Out and Use This PDF

Legal Transfer Form

3.Account Registration: (Example: John Smith OR John Smith and Mary Smith JT)

4.Street Address:

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5.Company:

TRANSFER SPECIFICS

Legal Transfer Form

NEW HOLDER/RECIPIENT INFORMATION

8.New Shareholder(s) Account Type - Check one:

Account Number - if existing: (2-6 digits after the dash) New Account Registration: (First, MI, Last) Individual / Trustee / Custodial / Executor / Other

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Name: (First, MI, Last) Joint Tenant / Co-Trustee / Minor / Beneficiary / Other (if applicable)

TAX PAYER ID CERTIFICATION (SUBSTITUTE W-9)

Please read the instructions carefully before completing the substitute W-9 form. All shareholders are required to sign and return this W-9 certification. If requested information is not known at time of transfer, or new owner is not available to sign, a W-9 form will be mailed to the new shareholder(s) once the shares are transferred. A new shareholder may also go online at www.shareholder.broadridge.com to print a W-9 form.

Your account may be subject to backup withholding, at the applicable rate, if you do not complete this substitute W-9 form.

CERTIFICATION: Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number,

(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 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. person (including U.S. resident alien).

(A second signature is required for a Joint Tenant Account)

Affidavit of Domicile

Broadridge Corporate Issuer Solutions

P.O. Box 1342

Brentwood, NY 11717-0718

Phone: (877) 830-4936

State of: ______________________________________________ County of: ________________________________________

Name of Stock (Issuer): ____________________________________________________________________________________

Name(s) of the Account: ________________________________ Name(s) of the Account: _______________________________

Deceased Holder’s Tax Identification Number (TIN) or Social Security Number: __________________________________________

I/We, the undersigned _________________________________________ being duly sworn, depose and say that (I/We) reside

at ___________________________________________________ in the state of ________________________________ am/are

_____________________________________ (describe your status such as Executive Administrator, Survivor in Joint Tenancy,

if a corporate fiduciary, show title of affiant and name of corporation) of __________________________________________

who died on the __________________________ day of _____________________, 20 ______ that at the time of death the

domicile (legal residency) of said decedent was at _____________________________________________________________

County of _______________________________ , State of ______________________________ that the decedent resided at

such address for ____________ years prior to death and was not a resident of any (other) State within the United States of

America at the time of death.

That any and all debts, taxes, legacies, and claims against the estate have been paid or provided for; that this affidavit is made for the purpose of securing the transfer or delivery of property owned by the decedent at the time of his/her death to a purchaser or the person or persons legally entitled thereto under the laws of the decedent’s domicile; and that any apparent inequality in distribution has been satisfied or provided for out of other assets in the estate.

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Sworn to before me, a notary public, this ________________________ Day of ________________________, 20 __________

Notary Public Commission Expires: __________________________