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THE EDELSTEINS

FAEGENBURGAugust 16, 2016

+ BROWN

FABIANI, COHEN & HALL, LLP

570 Lexington Avenue

New York, New York 10022

ATT: THOMAS J. HALL, ESQ.

FILE #828.37881

LESTER SCHWAB KATZ & DWYER, LLP

100 Wall Street,27d'

Floor

New York, New York 10005

ATT: CURT J. SHINER, ESQ.

FILE # 860-1328

RE: PRUSS V. INFINITI OF MANHATTAN, INC., ET AL.

INDEX # 161240/2013

Counsellors :

Pursuant to settlement made in the above entitled matter, enclosed herewith please find

duly executed duplicate original General Release for the amount of $8,875,000.00 (with hold

harmless agreement incorporated therein), together with Stipulation of Discontinuance executed

by this office, in triplicate.

The enclosed is to be held in escrow, by you, pending receipt by the undersigned of

settlement draft together with a copy of the Stipulation of Discontinuance signed by your office.

Upon receipt of the foregoing, you are hereby permitted to file the original stipulation. (For your

information enclosed is W9. Our EIN is 11-3541364).

DEMAND IS HEREBY MADE THAT PROMPT PAYMENT OF THIS SETTLEMENT

BE MADE IN ACCORDANCE WITH CPLR SECTION 5003 (a). IN THE EVENT THAT

PAYMENT IS NOT RECEIVED WITHIN TWENTY-ONE DAYS FROM THIS TENDER,

JUDGMENT WILL BE ENTERED AGAINST TH , DEFENDANT, WITH INTEREST

THEREON FROM THE DATE OF TENDER, PLUS TS AND DISBURSEMENTS.

V y r ors,

L . EDELSTEIN

Counsellors at Law

26 Broadway, Suite 901 - New York, NY 10004

0: (212) 425-1999 l F: (212) 425-5430 l efbfamilylaw.corn l efbpilaw.corn



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at 17 Kisufim st Jerusalem Israel . sthereby975 12snW Toonn $3 ,m2 1)nsu ,o$5W17$2I>Q

certify that the document overleaf is, to the1793W )7)pen ]noun 08 p))1To paya N10

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signature and seal today.11.08.2016.

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I the undersigned Ran Sivan Notary at 17 17 es910s3 21n12 197013 )po 17 n"nn nN

Kisufimst Jerusalem Israel hereby ceitify that D23'3 11.08.2016 oP2 >3 ,n12mnsetlat 1>~ ,00w17>2lJQ,D>081 l>3

on 11.8.2016 there appeared before me at myby O nnain nnnw no)N 0119 123 )T7wn2 MD5.8.201

. T 59 nN3lne 203171327 190n nini nT1yn 9office Ms PRUSS EITA whose identity was

n"own ]UD2 q opa o0wl173 5N1w)proved to me by Identity Booklet no. Toonn 59 wDinn nns7n nonni 10.06.2008

issued by Israel at Jerusalem on ,915(770 mayne10.06.2008 And signed of her own free will

one '2a 58 nnn>nn nN n/nnNn M)n n)N151the document overleaf. .11.08.201611.08.2016 own ,>nmnal ) nn>nna no)N

In witness where of I hereby authenticate the .ok)w n yo 5913 n"w 194 on I38signature of Ms. PRUSS EITA by my own

signature and seal today.11.8.2016..8.2016.

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NEW YORK GENERAL RELEASE

TO ALL TO WHOM THESE PRESENTS SHALL COME OR MAY CONCERN,KNOW THAT I, EITA PRUSS, residing at Jerusalem. Israel, as RELEASOR,in consideration of the sum of EIGHT MILLION ElGHT HUNDRED SEVENTY FIVE THOUSAND

Dollars and No Cents ($8,875,000.00), received from INFINITI OF MANHATTAN, INC, INFINITI

FINANCIAL SERVICES , INFINITI FINANCIAL LLC, MASSAMBA SECK, TOWER INSURANCE

COMPANY and GREAT AMERICAN INSURANCE COMPANY, as RELEASEE, receipt being

acknowledged, releases and discharges INFINITI OF MANHATTAN, INC., INFINITI FINANCl/\L

SERVICES, INFINITI FINANCIAL LLC, MASSAMBA SECK, TOWER INSURANCE COMPANY and

GREAT AMERICAN INSURANCE COMPANY, the RELEASEE, the RELEASEE's heirs, executors,

administrators, agents, successors and assignees from all actions, suits, debts, dues, sums of

money, accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies,

agreements, promises, variances, trespasses, damages, judgments, extents, executions, claims, and

demands whatsoever, in law, admiralty or equity, which against the RELEASEE, the RELEASOR, the

RELEASOR'S heirs, executors, administrators, agents, successors and assignees ever had, now

have or will ever have for, upon, or by reason of any matter, cause or thing whatsoever from the

.. beginning of time to the date of this RELEASE and any and all other claims arising out of an accident

/vhich occurred at on or about September 5, 2013

Releasor agrees to hold harmless and indemnify Releasee, from any and all liens and/or claims,

including rights of subrogation held by third parties, which may exist in relation to this matter,

including reasonableattorneys'

fees.

The parties have considered Medicare's interests in this settlement and have determined that

an allocation for future Medicare covered expenses is not required based upon the followingfactor: I affirm that I am not Medicare eligible.

The words "Releasor"and

"Releasee"include all Releasors and all Releasees, insurance carriers and

third-party administrators and Releasee's attorneys.

This RELEASE may not be changed orally.

IN WITNESS WHEREOF, the RELEASOR has hereunto set RELEASOR'S hand and seal on the

day of 0 , 2016.

In presence of

I Ro,bg L.S.

EITA PRUSS

JERUSALEM, ISRAEL

On Ef1 0 d , 2016 before me came EITA PRUSS, to me known, and known to me tobe the individual(s) described in, and who executed the foregoing RELEASE and duly acknowledgedto me that he/she executed the same.



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Form No. 399/2016 399/2016 v7 7Don

CERTIFICATION OF COPY f;fWf) NWN

I the undersigned Ran Sivan Notary Notary 17 asD1tna 21n12 1137o13 1130 11 n"nn uN

at 17 Kisuffm st Jerusalem Israel . sthereby119 12 DW TDUDD '2 PDC "D2D 2

certify that the document overleaf is, to theTWW )1ipen 1nDun 5W ps315n pn9n Nin

.DD3^thinWi33'lilld'71 n)533Nn nDW2best of my knowledge a correct copy of the

original document which is drawn up in the ,5"3n I prunn puT nN n/1WNu mn n)N151English language and has been produced to .11.08.2016 own ,>nninal $13 nosnna

me.

.pt W.,=~~ n"yn 5513 n"W 77 102313WIn witness where of I hereto set my own

signature and seal today.11.08.2016.'

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Serial No. 396/2016 396/2016 't con

AUTHENTICATION OF SIGNATURE hD)hh M10)N

I the undersigned Ran Sivan Notary at 17 17 o0010$3 31n12 F7013 p0 D n"nn $3M

Kisufim st.Jerusalem Israel hereby certify that nasu 11.08.2016 ol)2 )3 ,nt2IYZ 7)nse ,005W17)2I'2

on 11.8.2016 there appeared before me at my09 $5 annin animWno)N D179 /22 W7Wo2 $305

office Ms. PRUSS EITA whose identity was-)1) 09 nN2inW 203171327 Soon nint nmyn to

. n"own pon 't op2 o©W1103 5N7W)proved to me by Identity Booklet no. 3nonn 33 ,wainn n3137 n nu nni 10.06.2008203171327 issued by Israel at Jerusalem on .333,3yne-!3998

10.06.2008 And signed of her own free will

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0179 '2a 5W nna)nn nN n/nnNo u3n n)N1y)

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O RAN SIVAN

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TO ALL TO WHOM THESE PRESENTS SHALL COME OR MAY CONCERN,KNOW THAT l, EITA PRUSS, residing at Jerusalem. Israel, as RELEASOR,in consideration of the sum of ONE HUNDRED THOUSAND Dollars and No Cents ($100,000.00),

received from DENNIS C. BLANCHETTE, as RELEASEE, receipt being acknowledged, releases and

discharges DENNIS C. BLANCHEiTTE the RELEASEE, the RELEASEE's heirs, executors,

administrators, agents, successors and assignees from all actions, suits, debts, dues, sums of

I money, accounts, reckonings, bonds, bills, specialties, covenants, contracts, controversies,

agreements, promises, variances, trespasses, damages, judgments, extents, executions, claims, and

demands whatsoever, in law, admiralty or equity, which against the RELEASEE, the RELEASOR, the

RELEASOR'S heirs, executors, administrators, agents, successors and assignees ever had, now

have or will ever have for, upon, or by reason of any matter, cause or thing whatsoever from the

beginning of time to the date of this RELEASE and any and all other claims arising out of an accident

which occurred at on or about September 5, 2013



i f including reasonableattorneys'

fees.



The words"Releasor"

and"Releasee"

include all Releasors and all Releasees, insurance carriers and




day of , 2016.

In presence of

L.S.

EITA PRUSS

o JERUSALEM, ISRAEL

On { h O $ , 2016 before me came EITA PRUSS, to me known, and known to me tobe the individual(s) described in, and who executed the foregoing RELEASE, and duly acknowledged

to me that he/she executed the same.

I



Form No. 341/2016 341/2016 '! I 190n

CERTIFICATION OF COPY †7hyt) TWN

I the undersigned Ran Sivan Notary Notary 17 o$elo)3 31n73 1137013 11)o 17 n"nn >JN

at 17 Kisufim st Jerusalem Israel . sthereby175 12968 Tronn so ,ma Tn3D ,0)5W173 l>2

certify that the document overleaf is, to theP"17n pnyn M1n

.)3D3 331DW1 n)5)3ND DDW3best of my knowledge a correct copy of the

original document which is drawn up in the ,5 3n pnsnn pin nN n/7WNo mn n)N151English language and has been produced to .11.08.2016 own ,)nmnal n) nn>nna

me.

.D5lW n"yn 5513 n"W 31 103313WIn witness where of I hereto set my own


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Serial No. 398/2016 398/2016 111con

AUTHENTICATION OF SIGNATURE hD)Mh h12*N

I the undersigned Ran Sivan Notary at 17 17 o)010)2 21n12 ]1)1013 11)o 11 n"nn $3N

Kisufim st Jerusalem Israel hereby certify that n2333 11.08.2016 ol)2 $2 ,nta1>nsel>rlMQ ,0)5w11)2587 j

on 11.8.2016 there appeared before me at my 59'5 0D310 D lntW no)N o170 'n) W1Won $305. m by nNsinw 203171327 190n ills) DT1yn >D

office Ms. PRUSS EITA whose identitywasn"own 11)o2 't ol)2 o)5w11)2 5N1ws

proved to me by Identity Booklet no. Toonn 59 swo1nn nns1n annn1 10.06.2008203171327 issued by Israel at Jerusalem on .97512yow.~j fJ 133iQ810.06.2008 And signed ofherownfreewill

t37 lQ , 98 ,nn nN n/DnNo >nn n)N151the document overleaf. 11.08.2016 01)il ,)nninai rn nosnna no)N

In witness where of I hereby authenticate the Q"3iQ 00D jl "8signature ofMs. PRUSS EITA by my own

.D51$ 194 TU2 '73W

signature andsealtoday.11.8.2016.


/g~! RAN SIVAN

Signature0, RAN S)VAN

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TO ALL TO WHOM THESE PRESENTS SHALL COME OR MAY CONCERN,KNOW THAT I, EITA PRUSS, residing at Jerusalem. israel, as RELEASOR.

in consideration of the sum of TWENTY FIVE THOUSAND Dollars and No Cents ($25,000.00),

received from JON-PAUL PvORECH. as RELEASEE, receipt being acknowledged, releases and

discharges JON-PAUL RORECH, the RELEASEE, the RELEASEE's heirs, executors, administrators,

agents, successors and assignees frohl all actions, suits, debts, dues, sums of money, accounts

reckonings, bonds, bills, specialties, covenants, contracts, controversies, agreements, promises,

variances, trespasses, damages, judgments, extents, executions, claims, and demands whatsoever,in law, admiralty or equity, which against the RELEASEE, the RELEASOR, the RELEASOR'S heirs,

executors, administrators, agents, successors and assignees ever had, now have or will ever have

for, upon, or by reason of any matter, cause or thing whatsoever from the beginning of time to the

date of this RELEASE and any and all other claims arising out of an accident which occurred at on or

about September 5, 2013



including reasonableattorneys'

fees.



The words"Releasor"

and"Releasee"

include all Releasors and all Releasees, insurance carriers and




day of 2 , 2016.

n presence of

ITR PI<t 6 L.S.

EITA PRUSS

JERUSALEM, ISRAEL

On . - a f , 2016 before me came EITA PRUSS, to me known, and known to me tobe the individual(s) described in, and who executed the foregoing RELEASE, and duly acknowledgedto me that he/she executed the same.



SUPREME COURT OF THE STATE OF NEW YORK INDEX # 161240/13

COUNTY OF NEW Y ORK------------------------------------ - - -x

EITA (ITTY) PRUSS

Plaintiff-against- STIPULATION OF

DISCONTINUANCE

INFlNITI OF MANHATTAN, INC., INFINITI

FINANCIAL SERVICES, INFINITI FINANCIAL

LLC, MASSAMBA SECK, DENNIS C. BLANCHETTE,JON-PAUL RORECH and STIFEL, NICOLAUS &

COMPANY, INC.

Defendants-------------------------------------- -x

IT IS HEREBY STIPULATED AND AGREED by and between the undersigned, the attorneys of

record for all the parties in the above entitled action, that whereas no party hereto is an infant or incompetent

person for whom a committee has been appointed and no person not a party has an interest in the subject

matter of the action, the above entitled action be, and the same hereby is discontinued, with prejudice, without

costs to either party as against the other. This stipulation may be filed without further notice with the Clerk of

the Court.

Dated: New York, New York

August 16, 2016

FABIANI, COHEN & HALL, LLP HE STEINS, FAEGENBURG & BROWNCo-Attys for Defts, INFINITI/SECK Attor ys for Plaintiff

570 Lexington Avenue 26 oadway, Suite 901

New York, New York 10022 w York, New York 10004

LESTER SCHWAB KATZ & DWYER PILLINGER MILLER TARALLO, LLP

Co-Attys for Defts, INFINITI/SECK Attorneys for Defendant, DENNIS C. BLANCHETTE

100 Wall Street 570 Taxter Road, Suite 275

New York, New York 10005 Elmsford, NewYork 10523

PICCIANO & SCAHILL P.C.

Attorneys for Defendant, JON-PAUL RORECH

900 Merchants Concourse, Suite 310

11590Westbury, New York



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Form W-9 Request for Taxpayer Give Form to the

RevsernbeheTr ury Identification Number and Certification ,°,9n"o°to e °ss.

InternalRevenueService1 Name(asshown on your income tax return).Nameis requiredon this line;do not leavethis lineblank.

THE EDELSTEINS, FAEGENBURG & BROWN LLP2 Businessname/disregardedentity name, if different from above

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3 Check appropriate box for federal tax classification;check only one of the followingsevenboxes: 4 Exemptions(codesapply only to

0 Individual/soleproprietoror O C Corporation Q S Corporation O Partnership p Trust/estate instructionscertain

onentities,

panot

3):Individuals;sse

o 2 single-memberLLCg Q

Exemptpayeecode(ifany).4-; Limitedliability company.Enter the tax classification(C=Ccorporation,S=Scorporation, P=partnership)»

o Note. Fora single-memberLLC that is disregarded,do not check LLC;check the appropriatebox in the lineabove for Exemptionfrom FATCAreporting

c the tax classificationof the single-memberowner. code (if any)~Ct

cQ Other (seeinstructions)Þ SppestoaccountsmadsinedodsidemeusJ

5 Address (number,street,and apt. or suite no.) Requester'snameand address(optional)

& 26 BROADWAY, SUITE 901r/I 6 City, state, and ZIP code(a NEW YORK, NEW YORK 10004

7 List account number(s)here(optional)

H Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid | Social security number

backup withholding. For individuals, this is generally your social security number (SSN). However, for aresident 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 aTIN on page 3. or

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for Employer identification numberguidelines on whose number to enter.

1 1 - 3 5 4 1 3 6 4

CertificationUnder 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 RevenueService (1RS)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 amno longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and4. 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 withholdingbecause you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgageinterest paid, acquisition or aban ent of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), andgenerally, payments other than

'ter t and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the

instructions on page 3.Sign signature of g /g /cHere u.S.person > Date >

General Instructio• Form1098 (homemortgage Interest),1098-E(studentloan interest).1098-T(tuItion)

Section referencesare to the Int mal RevenueCode unlessotherwise noted. • Form 1099-C(canceleddebt)Future developments. Informationabout developmentsaffecting FormW-9 (such * Form 1099-A(acquisitionor abandonmentof securedproperty)as legislationenacted after we releaseit) is at www.irs.govlfw9.

Use FormW-9only if you are a U.S.person (includinga residentalien),toPurpose of Form provideyour correctTIN.

An individualor entity (FormW-9 requester)who is requiredto file an information If you do not return Form W-9 to the requesterwith a TIN,you might be subjectreturn with the IRSmust obtain your correct taxpayer identificationnumber(TIN) to backup withholding.See Whatis backupwithholding?on page2.which maybe your social securitynumber (SSN),individualtaxpayer identification By signing the filled-out form, you:number(ITIN),adoption taxpayer identification number (ATIN),or employer 1.Certify that the TIN you are giving is correct (or you arewaiting for a numberidentificationnumber (EIN),to reporton an information return the amountpaid toyou, or otheramount reportableon an information return.Examplesof information to be issued),returns include,but arenot limited to, the following: 2. Certify that you arenot subject to backupwithholding, or• Form 1099-INT(interestearnedor paid) 3. Claimexemption from backup withholding if you are a U.S.exempt payee.If• Form 1099-DIV(dividends, includingthose from stocks or mutual funds) applicable,you arealso certifying that as a U.S. person,your allocableshareof

any partnershipincornefrom a U.S. trade or businessis not subject to the• Form 1099-MISC(varioustypesof income, prizes, awards,or gross proceeds) withholding tax on foreign partners' shareof effectivelyconnected income,and• Form 1099-8 (stock or mutual fund salesand certain other transactionsby 4. Certify that FATCAcode(s)enteredon this form (if any)indicatingthat you arebrokers) exempt from the FATCAreporting, is correct. See Whatis FATCAreporting? on• Form 1099-S(proceedsfrom realestate transactions) page2 for furtherinformation.• Form 1099-K(merchantcard and third party network transactions)

Cat. No. 10231X FormVl-9 (Rev.12-2014)



name."

Forrn W-9(Rev.12-2014) Page2

Note. If youarea U.S.personanda requestergivesyou a formother than Form 3. The IRStells the requesterthat you furnishedan incorrectTIN,W-9 to requestyourTIN,you mustusethe requester's form if it is substantially 4. The IRStells you that you are subject to backup withholding becauseyou didto this FormW-9. not report all your interestand dividendson your tax return(for reportableinterestDefinition of a U.S.person. Forfederaltax purposes, youareconsidered a U.S. and dividendsonly),orperson if youare: 5. You do not certify to the requesterthat you are not subject to backup• An individualwho is a U.S.citizenor U.S. resident alien; withholding under4 above(for reportableinterestand dividend accountsopened• A partnership,corporation,company,or associationcreatedor organized in the after 1983only).United Statesor underthe laws of the United States; Certainpayeesand paymentsare exemptfrom backupwithholding.See Exempt• An estate(otherthana foreignestate);or payeecode on page3 and the separateInstructionsfor the Requesterof Form

W-9 for more Information.• A domestictrust (asdefinedInRegulationssection 301.7701-7).

Also seeSpecialrulesfor partnershipsabove.Special rules for partnerships. Partnershipsthat conduct a tradeor businessinthe UnitedStatesaregenerallyrequiredto pay a withholdingtax under section What is FATCA reporting?1446 onany foreignpartners'shareof effectively connectedtaxable income fromsuch business.Further,in certaincaseswhere a FormW-9 hasnot been received, The ForeignAccountTax ComplianceAct (FATCA)requiresa participatingforeignthe rulesundersection 1446requirea partnership to presumethat a partner is a financial institutionto report all United Statesaccount holders that arespecifiedforeign person,and pay the section 1446withholding tax. Therefore,if you are a United Statespersons.Certain payeesareexempt from FATCAreporting.SeeU.S. personthat is a partner Ina partnershipconducting a tradeor business in the Exemptionfrom FATCAreporting code on page 3 and the Instructionsfor theUnited States,provideFormW-9to the partnership to establishyour U.S. status Requesterof FormW-9 for more information.and avoidsection 1446withholdingon your share of partnershipincome.

Updating Your InformationIn the casesbelow, the followingperson must give FormW-9 to the partnershipfor purposesof establishingits U.S.status and avoidingwithholdingon its You must provideupdated information to anyperson to whom youclaimed to beallocable shareof net incomefrom the partnership conductinga trade or business an exempt payeeif you are no longeran exempt payeeand anticipatereceivingin the UnitedStates: . reportablepaymentsin the future from this person. For example,you may need to• In the caseof a disregardedentitywith a U.S. owner, the U.S.owner of the provide updated informationif you are a C corporation that elects to be an Sdisregardedentityand not the entity; corporation, or if you no longer are tax exempt. In addition,you mustfurnish a new

FormW-9 if the nameor TIN changesfor the account; for example,if the grantor• In the caseof a grantortrust with a U.S.grantor or other U.S.owner, generally, of a grantor trust dies.the U.S.grantoror other U.S.ownerof the grantor trust andnot the trust; and• In thecaseof a U.S. trust (otherthan a grantor trust), the U.S.trust (other than a Penaltiesgrantor trust)and not the beneficiariesof the trust. Fallure to furnish TIN. If you fail to furnishyour correct TINto a requester,you areForeign person. If you area foreignperson or the U.S. branchof a foreign bank subject to a penaltyof $50 for each such failureunlessyour failureIsdue tothat haselectedto be treated asa U.S.person, do not useFormW-9. Instead,use reasonablecauseand not to willful neglect.the appropriateFormW-8 or Form8233(see Publication515,Withholdingof Tax Civil penalty for false information with respect to withholding. If you make aon NonresidentAliensand ForeignEntitles). false statementwith no reasonablebasisthat results in no backupwithholding,Nonresident alien who becomes a resident alien. Generally,only a nonresident you are subject to a $500penalty.alien individualmay usethe terms of a tax treaty to reduceor eliminateU.S. tax on Criminal penalty for falsifying information. Willfully falsifyingcertificationsorcertain typesof income.However,most tax treaties containa provision known as affirmationsmaysubjectyou to criminal penaltiesincludingfines and/ora "saving clause.clause."Exceptionsspecifiedin the saving clausemaypermit an imprisonmentexemption from tax to continue for certain types of incomeevenafter the payeehas otherwisebecomea U.S. residentalien for tax purposes. Misuse of TINs. If the requesterdisclosesor usesTINs in violationof federal law,

. . the requestermaybe subject to civil and criminal penalties.If youare a U.S.residentalienwho is relying on an exceptioncontained in the

saving clauseof a tax treaty to claiman exemption from U.S.tax on certain types . .of income,you mustattach a statementto Form W-9 that specifiesthe following SpeCIflC lnStrUCtiOnSfive items:

1. Thetreatycountry.Generally,this must be the sametreatyunder which you Line 1claimed exemptionfrom tax as a nonresidentalien. You must enteroneof the following on this line; do not leavethis lineblank. The

2. Thetreatyarticleaddressingthe income. name should matchthe name on your tax return.

3. Thearticlenumber(or location) in the tax treaty that containsthe saving If this FormW-9 is for a joint account, list first, and thencircle, the nameof theclause and its exceptions. person or entitywhosenumber you enteredin Part I of FormW-9.

4. Thetype andamountof incomethat qualifies for the exemptionfrom tax. a. Individual. Generally,enter the nameshown on your tax return.If you havechanged your lastnamewithout informingthe Social SecurityAdministration(SSA)5. Sufficientfacts to justify the exemption from tax underthe terms of the treaty of the namechange,enteryour first name,the last nameas shownon your socialsecurity card, andyour new last name.

Example. Article20 of the U.S.-Chinaincome tax treatyallowsan exemption Note. ITIN applicant: Enteryour individualname as it was enteredon your Formfrom tax for scholarshipincome receivedby a Chinesestudenttemporarily present W-7 application,line1a.This should alsobe the same asthe nameyou entered onin the UnitedStates.UnderU.S. law, this student will becomea resident alien for the Form 1040/1040A/1040EZyou filed with your application.tax purposesif his or her stay in the United States exceeds5 calendaryears.However,paragraph2 of the first Protocol to the U.S.-Chinatreaty(dated April 30, b. Sole proprietor or single-member LLC. Enteryour Individualnameas1984)allowsthe provisionsof Article20 to continue to applyevenafter the shown on your 1040/1040A/1040EZon line1. You mayenter yourbusiness,trade,Chinesestudentbecomesa residentalien of the UnitedStates.A Chinesestudent or 'ng businessas" (DBA)nameon line2.who qualifiesfor this exception (underparagraph 2 of the first protocol) and is c. Partnership, LLCthat is not a single-member LLC, C Corporation, or Srelying on this exceptionto claim an exemption from tax on hisor her scholarship Corporation. Enterthe entity's nameas shown on the entity's tax returnon line 1or fellowshipincomewould attach to Form W-9 a statementthat includes the and any business,trade,or DBA nameon line 2.informationdescribedabove to support that exemption. d. Other entities. Enteryour name as shown on requiredU.S. federaltax

If youare a nonresidentalienor a foreign entity, give the requesterthe documents on line1.Thisname should match the nameshownon the charter orappropriatecompletedFormW-8 or Form 8233. other legaldocumentcreating the entity. You may enteranybusiness,trade, or

DBA nameon line2.Backup Withholding e. Disregarded entity. For U.S. federal tax purposes,an entity that isWhat is backup withholding? Personsmaking certain paymentsto you must disregardedas anentity separate from its owner is treated as a "disregardedunder certainconditionswithhold and pay to the IRS2855of such payments.This entity." SeeRegulationssection 301.7701-2(c)(2)(iii).Enterthe owner'sname onis called "backupwithholding." Paymentsthat may be subjectto backup line 1.The nameof the entity entered on line 1 should neverbe a disregardedwithholding includeinterest, tax-exemptinterest, dividends,brokerand barter entity. Thenameon line 1 should be the name shown on the incometax return onexchangetransactions,rents, royalties,nonemployee pay,paymentsmade in which the incomeshould be reported. Forexample, if a foreignLLCthat is treatedsettlementof paymentcard and third party network transactions,and certain as a disregardedentity for U.S. federal tax purposes hasa singleowner that is apaymentsfrom fishingboat operators.Realestate transactionsare not subject to U.S. person,the U.S.owner's name is requiredto be providedon line 1. If thebackup withholding. direct ownerof the entity is also a disregardedentity, enterthe first owner that is

. . not disregardedfor federal tax purposes.Enter the disregardedentity's name onYou will not be subject to backupwithholding on paymentsyou receive if you line 2, "Businessname/disregardedentityname." If the ownerof the disregardedgive therequesteryour correct TIN,make the proper certifications,and report all

entity is a foreignperson,the owner must complete an appropriateFormW-8your taxableinterestand dividendson your tax return. instead of a FormW-9. This is the case even if the foreignpersonhasa U.S. TIN.Payments you receive will be subject to backup withholding if:

1. Youdo not furnishyour TIN to the requester,2. You do not certify your TIN whenrequired (seethe Part11instructions on page

3 for details),



â€”

â€”

â€”

â€”

â€”

Form W-9(Rev.12-2014) Page3

Line 2 "However,the followingpaymentsmade to a corporationand reportableon Formif you havea businessname,tradename,DBAname,or disregardedentity name, 1099-MISCarenot exempt from backup withholding:medicaland healthcareyou mayenter it on line 2. payments,attorneys'fees,gross proceedspaid to an attorneyreportableunder

section6045(f),and paymentsfor servicespaid by a federalexecutiveagency.Une 3 Exemption from FATCAreporting code. The followingcodes identify payeesCheck theappropriatebox in line3 for the U.S. federal tax classificationof the that areexemptfrom reportingunder FATCA.Thesecodes apply to personsperson whosenameis enteredon line 1.Check only one box in line3. submittingthis form for accountsmaintainedoutsideof the United States byLimited Llability Company (LLC}. If the name on line 1 is an LLC treatedas a certainforeignfinancialInstitutions.Therefore,if you areonly submitting this form

partnershipfor U.S.federal tax purposes,check the "LimitedLiability Company" for anaccountyou hold Inthe United States,you mayleavethis field blank.box andenter"P" in the space provided. If the LLC has filed Form8832 or 2553 to Consultwith the person requestingthis form if you areuncertainif the financialbe taxed asa corporation,check the "Umited LlabilityCompany"box and in the restitutionis subject to theserequirements.A requestermay indicate that a code isspace providedenter "C" for C corporation or "S" for S corporation. If it isa cot requiredby providingyou with a FormW-9 with "Not Applicable (oranysingle-memberLLCthat is a disregardedentity, do not check the "Limited Liability

similarindication)written or printed on the line for a FATCAexemptioncode.Company" box; insteadcheck the first box in line3 "Individual/soleproprietoror A-An organizationexempt from tax undersection501(a)or any individualsingle-memberLLC.• retirementplanas defined in section 7701(a)(37)

B-The UnitedStatesor any of its agenciesor instrumentalitiesLine 4, Exemptionsâ€”

C-A state, the Districtof Columbia,a U.S.commonwealthor possession,orIf you areexempt from backup withholding and/or FATCAreporting,enter in the anyof their politicalsubdivisionsor instrumentalitiesappropriatespace in line4 any code(s)that may apply to you.D-A corporationthe stock of which is regularlytraded on one or moreExempt payee code' establishedsecuritiesmarkets,as described In Regulationssection

• Generally,individuals(includingsole proprietors)arenot exempt from backup 1.1472-1(c)(1)(i)withholding. E-A corporationthat is a member of the sameexpandedaffiliated group as a• Exceptas provided below, corporationsareexempt from backup withholding corporationdescribedin Regulationssection 1.1472-1(c)(1}(i)for certainpayments,Includinginterest anddividends. F-A dealer in securities,commodities, or derivativefinancialinstruments• Corporationsarenot exempt from backup withholding for paymentsmade in (includingnotionalprincipalcontracts, futures,forwards,and options)that issettlementof paymentcard or third party network transactions. registeredassuch under the laws of the UnitedStatesor anystate• Corporationsarenot exempt from backup withholdingwith respect to attorneys' G-A real estateinvestmenttrustfees or grossproceedspaid to attorneys,and corporationsthat provide medicalor H-A regulatedinvestmentcompany as defined in section851 or anentityhealth careservicesarenot exemptwith respect to paymentsreportableon Form registeredat all times during the tax year under the InvestmentCompanyAct of1099-MISC. 1940

The followingcodes Identify payeesthat areexempt from backup withholding. I-A common trust fund as defined in section 584(a)Enter theappropriatecode In the space in line 4.â€”

â€”1-An organizationexempt from tax undersection 501(a),any IRA,or aâ€”J-A bank asdefined in section 581

custodial accountundersection 403(b)(7)if the account satisfies therequirements K-A brokerof section401(f)(2) L-A trust exempt from tax under section 664 or describedin section 4947(a)(1)

2-The United Statesor any of its agenciesor instrumentalities M-A tax exempt trust under a section 403(b)planor section457(g)planâ€”3-A state,the Districtof Columbia, a U.S. commonwealthor possession,or Note. You maywish to consultwith the financialinstitutionrequestingthis form to

any of theirpoliticalsubdivisionsor instrumentalities determinewhetherthe FATCAcode and/or exemptpayeecode should be4-A foreigngovernmentor anyof its political subdivisions,agencies,or completed.

instrumentalitiesLine 5â€”5-A corporation

. Enteryour address(number,street, and apartmentor suitenumber).This is whereâ€”6-A dealerin securitiesor commodities required to register in the United the requesterof this FormW-9 will mail your Informationretums.States, the Districtof Columbia,or a U.S.commonwealthor possession

â€”7-A futurescommissionmerchant registeredwith the Commodity Futures Line 6Trading Commission Enteryour city, state, andZIP code.

â€”8-A realestateinvestmenttrustâ€”9-An entity registeredat all times during the tax year under the Investment Part 1. Taxpayer Identification Number (TIN)

CompanyAct of 1940 Enter your TIN in the appropriate box. If you area residentalienand you do not10-A commontrust fund operated by a bank under section584(a) haveandare not eligibleto get an SSN,your TIN is your IRSindividualtaxpayer

Identificationnumber(ITIN).Enter it in the social securitynumberbox. If you do not11-A financialinstitution havean ITIN,seeHow to get a TIN below.â€”12-A middlemanknownIn the investmentcommunityas a nomineeor If youare a sole proprietor and you havean EIN,you mayentereitheryour SSNcustodian or EIN.However,the IRSprefers that you use your SSN.

13-A trust exernptfrom tax under section664 or described in section 4947 If you are a single-memberLLC that is disregardedas an entityseparatefrom itsThe followingchart shows types of paymentsthat may be exempt from backup owner(seeLimitedUability Company(LLC)on this page),enterthe owner's SSN

withholding. Thechart applies to the exempt payeeslisted above, 1 through 13. (or EIN,if the owner hasone).Do not enter the disregardedentity's EIN.If the LLCis classifiedas a corporation or partnership,enterthe entity's EIN.

IF the payment Is for . . . THEN the payment is exempt for . . . Note. See the chart on page4 for further clarificationof nameand TINcombinations.

Interest and dividendpayments All exempt payeesexcept How to get a TIN. If youdo not havea TIN,apply for one immediately.To applyfor 7 for anSSN,get FormSS-5,Application for a SocialSecurityCard, from your local

SSAoffice or get this formonline at www.ssa.gov.You mayalsoget this form byBroker transactions Exempt payees1 through 4 and 6 calling 1-800-772-1213.Use FormW-7, Application for IRSIndividualTaxpayer

through 11 and all C corporations.S IdentificationNumber, to apply for an ITIN,or FormSS-4,Application for Employercorporationsmust not enter an exempt IdentificationNumber, to apply for an EIN.You can apply for an EIN onlinebypayeecode becausethey are exempt accessingthe IRSwebsite at www.irs.gov/businessesand clickingon Employeronly for salesof noncoveredsecurities IdentificationNumber(EIN)under Starting a Business.You canget FormsW-7 andacquired prior to 2012. SS-4 from the IRSby visiting IRS,govor by calling 1-800-TAX-FORM

(1-800-829-3676).Barter exchangetransactionsand Exempt payees1 through 4 If you areaskedto complete FormW-9 but do not haveaTIN,apply for a TINpatronagedividends and write "AppliedFor" in the space for theTiN, sign anddate the form, and give itPa mentsover $600required to be Generally,exemptpayees to the requester.For interestand dividend payments,and certainpaymentsmade

2 with respect to readily tradableinstruments,generallyyou will have60 days to getreported and direct salesover $5,000 1 through 5 aTIN and give It to the requesterbefore you aresubject to backupwithholding onpayments.The60-day ruledoes not apply to other types of payments.You will be

Paymentsmade in settlementof Exempt payees1 through 4 subject to backupwithholding on all such paymentsuntil you provideyour TIN topayment card or third party network therequester.transactions Note. Entering"Applied For" meansthat you havealreadyappliedfor aTiN or thati . you intend to apply for one soon.

See Form1099-MISC,MiscellaneousIncome,and its instructions.Caution: A disregardedU.S.entity that hasa foreignownermust use theappropriat FormW-H.



grantor-trustee'

owner'

Form W-9(Rev.12-2014) Page4

Part II. Certification *YoumustshowyourindividualnameandyoumayalsoenteryourbusinessorDBAnameonthe"Businessname/disregardedentity"nameline.YoumayuseeitheryourSSNorSN(ifyouTo establishto the withholding agentthat you are a U.S. person,or residentalien, haveone),buttheIRSencouragesyoutouseyourSSN.sign FormW-9.You may be requestedto sign by the withholdingagenteven if ' Listfirstandcirclethenameofthetrust,estate,orpensiontrust.(DonotfurnishtheTINoftheitems 1,4, or 5 below indicateotherwise. personalrepresentativeortrusteeunlessthelegalentityitselfisnotdesignatedintheaccount

For a joint account,only the personwhoseTIN is shown in Part I should sign title.)AlsoseeSpecialrulesforpartnershipsonpage2.(when required).In the case of a disregardedentity, the personidentifiedon line 1 *Note.GrantoralsomustprovideaFormW-9totrusteeoftrust.must sign.Exemptpayees,seeExemptpayeecode earlier. Note. If no nameis circledwhen more than one nameis listed, the numberwill beSignature requirements. Completethe certification as indicatedin items 1 consideredto be that of the first name listed.through 5 below

Secure Your Tax Records from Identity Theft1. Interest, dividend, and barter exchan.geaccounts opened before 1984and broker accounts considered active during 1983, Youmustgive your Identity theft occurs whensomeone usesyour personalinformationsuchas yourcorrect TIN,but you do not have to sign the certification. name,SSN, or other identifyinginformation,withoutyour permission,to commit

2. Interest, dividend, broker, and barter exchange accounts opened after fraudor other crimes.An Identity thief mayuseyourSSN to get a job or mayfile a1983 and broker accounts considered inactive during 1983.Youmust sign the tax return using your SSNto receivea refund.certificationor backupwithholding will apply. if you are subject to backup To reduce your risk:withholding and you are merelyprovidingyour correct TIN to the requester,you • Protect your SSN,must crossout item2 in the certificationbefore signing the form. • Ensureyour employeris protecting your SSN,and3. Realestate transactions. You must sign the certification.You may cross outitem 2 of the certification. • Becareful when choosinga tax preparer.

4. Other payments. You must giveyour correct TIN, but you do not have to sign If your tax records areaffected by Identitytheft andyou receivea noticefromthe certificationunlessyou have been notifiedthat you havepreviouslygiven an the IRS, respondright awayto the nameand phonenumber printedon the IRSincorrectTIN. "Otherpayments" includepaymentsmade in the courseof the noticeor letter.requester'strade or businessfor rents, royalties,goods (otherthan bills for Ifyour tax recordsarenot currently affectedby identity theft but you thinkyoumerchandise),medicaland health careservices(including paymentsto areat risk due to a lostor stolen purse ar wallet,questionablecredit card activitycorporations),paymentsto a nonemployeefor services, paymentsmade in or credit report, contact the IRSIdentity TheftHotlineat 1-800-908-4490or submitsettlementof paymentcard and third party network transactions,paymentsto Form14039.certain fishingboat crew membersand fishermen,and gross proceedspaid to Formore information,see Publication4535, IdentityTheft PreventionandVictimattorneys(includingpaymentsto corporations). Assistance.

5. Mortgage Interest paid by you, acquisition or abandonment of secured Victims of identity theft who are experiencingeconomicharm or a systemproperty, cancellation of debt, qualified tuition program payments (underproblem,or are seekinghelp in resolvingtax problemsthat have not beenresolvedsection 529),IRA, Coverdeli ESA,Archer MSA or HSA contributions or through normalchannels,may be eligible for TaxpayerAdvocate Service(TAS)distributions, and pension distributions. You must give your correctTIN, but you assistance.You can reachTASby callingthe TAStoll-free case intakelineatdo not haveto sign the certification. 1-877-777-4778or TTY/TDD1-800-829-4059.

What Name and Number To Give the Requester Protect yourself from suspicious emails or phishing schemes. Phishingis thecreation and useof emailand websites designedto mimic legitimatebusiness

For this type of account: Give name and SSN of: emailsand websites.Themost common act is sendinganemail to a userfalsely. claiming to be anestablishedlegitimate enterprisein an attempt to scamthe user1. Individual The individual intosurrenderingprivateinformation that will be usedfor identity theft.

2. Twoor more individuals(joint Theactual ownerof the account or,account) if combined funds, the first The IRSdoes not initiatecontacts with taxpayersvia emails.Also,the IRSdoes

. , not request personaldetailedinformation through emailor ask taxpayersfor theindividual on the account PINnumbers, passwords,or similar secretaccess information for their credit card,3. Custodianaccountof a minor Theminor'minor bank,or other financialaccounts.

(UniformGift to MinorsAct) If you receivean unsolicitedemail claimingto be from the IRS,forwardthis4. a.Theusualrevocablesavings Thegrantor-trustee' messageto [email protected] may also report misuseof the IRSname,logo,

trust (grantoris also trustee) or other IRSpropertyto the TreasuryInspectorGeneralfor Tax Administrationb. So-calledtrust account that is The actual owner'owner (TIGTA)at 1-800-366-4484.You can forwardsuspiciousemails to the Federalnot a legalor valid trust under TradeCommissionat: [email protected] contact them at www.ftc.govlidtheff orstatelaw 1-877-IDTHEFT(1-877-438-4338).

5. Soleproprietorshipor disregarded The owner' Visit IRS.govto learnmore about identity theft and how to reduceyour risk.entityowned by an individual

6. Grantortrust filing under Optional The grantor'privacy Act Notice

Form1099FilingMethod 1 (seeRegulationssection 1.671-4(b)(2)(i) Section 6109 of the InternalRevenueCoderequiresyou to provideyour correct(A)) TINto persons (includingfederalagencies)who are required to file information

with the IRSto report interest, dividends,or certainother incomepaid toFor this type of account: Give name and EIN of: you;mortgage interestyou paid; the acquisitionor abandonmentof secured7. Disregardedentity not owned by an The owner property; the cancellationof debt; or contributionsyou made to an IRA,Archer

individual MSA,or HSA.Thepersoncollecting this form usesthe informationon the form to8. A valid trust, estate,or pensiontrust Legalentity' file information returnswith the IRS,reportingthe above information.Routineuses

of this informationincludegiving it to the Departmentof Justice for civil and9. Corporationor LLCelecting The corporation criminal litigation and to cities, states, the District of Columbia, and U.S.

corporatestatus on Form 8832or commonwealthsand possessionsfor use in administeringtheir laws.TheForm2553 informationalsomay be disclosed to othercountriesunder a treaty, to federaland

10. Association,club, religious, The organization state agencies to enforcecivil and criminallaws, or to federal law enforcementandcharitable,educational,or other tax. intelligenceagenciesto combat terrorism.You must provide your TINwhetherorexemptorganization notyou are requiredto file a tax return. Undersection3406, payersmustgenerally

. . withhold a percentageof taxable interest,dividend,and certain otherpaymentsto11. Partnershipor multi-memberLLC The partnership a payeewho does not give aTIN to the payer.Certainpenaltiesmayalsoapply for12. A brokeror registerednominee The broker or nominee providing false or fraudulentinformation.13. Accountwith the Departmentof The public entity

Agriculturein the nameof a publicentity (suchas a state or localgovernment,schooldistrict, orprison)that receivesagriculturalprogrampayments

14. Grantortrust filing under the Form The trust1041Filing Methodor the OptionalForm1099 FilingMethod 2 (seeRegulationssection 1.671-4(b)(2)(i)(B))

I Listfirstandcirclethenameof thepersonwhosenumberyoufurnish.IfonlyonepersononajointaccounthasanSSN,thatperson'snumbermustbe furnished.

2Circlethe furnish SSN.minor'snameand theminar's



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