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Fidelity Fixed Income Indexed Annuity by rdq12378

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									OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:



   Fixed Annuities


   OMGuarantee-Platinum 3 ™ (3MYGAR & 3MYGAM)
   All States Except MN
       First Year       First Year       Renewal
    Issue Age Last   Issue Age Last
        Birthday         Birthday
       Age 0-79         Age 80-90

       1.500%           0.750%            None




   OMGuarantee-Platinum 5 ™ (5 Yr. Guar)
   (SG05M, SB05M, SG05T)
   All States Except MN
      First Year       First Year        Renewal
      Issue Age        Issue Age
         0-79            80-90

       2.500%           1.250%            None




   OMGuarantee-Platinum 7 ™ (7 Yr. Guar)
   (SG07M, SG07T, SB07MR)
   All States Except MN
      First Year       First Year        Renewal
      Issue Age        Issue Age
         0-79            80-90

       3.250%           1.625%            None




   OMGuarantee-Plus - 7™ (7 Yr. Guar)
   (SG07P, SG07PT, SB07M, SB07MR)
   All States Except MN)
      First Year       First Year        Renewal
      Issue Age        Issue Age
         0-79            80-90

       3.250%           1.625%            None




   OMGuarantee-Plus 3 ™ (3MYGAP & 3MYGAN)
   All States Except MN
       First Year       First Year       Renewal
    Issue Age Last   Issue Age Last
        Birthday         Birthday
       Age 0-79         Age 80-90

       1.500%           0.750%            None




   OMGuarantee-Plus 5 ™ (5 Yr. Guar)
   (SG05P, SG05PT, SB05MP)
   All States Except MN
      First Year       First Year        Renewal
      Issue Age        Issue Age
         0-79            80-90

       2.500%           1.250%            None



   Immediate Annuities




                                                                       Page 1 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OM Immediate-Income (FIDS42 and FIDS46)
      Issue Age      Issue Age 90+       Renewal
         0-89
        2.0000           0.0000            None


   OMImmediate-Safeguard ™ - Balloon Benefit Payout Period (FIDS45)
         Year             Year             Year             Year          Year            Year             Year     Year     Year    Renewal
          2                3                4                5             6               7                8        9       10+
       1.500%           3.000%           5.500%           7.500%        7.500%           7.500%           7.500%   7.500%   9.500%    None


   OMImmediate-Safeguard ™ - Level Benefit Payout Period (FIDS45)
         Year             Year             Year             Year          Year            Year             Year     Year     Year    Renewal
          2                3                4                5             6               7                8        9       10+
       1.000%           2.000%           2.500%           4.000%        5.000%           6.000%           7.000%   7.500%   9.500%    None



   Index Annuities


   OM Index-Safety 10 ™ All States Except TX and WA
       Standard         Standard        Commission        Renewal
    Compensation     Compensation        Option 2 -
    Option 1 - $1    Option 1 - $1     1.00% Trail -
       M & Less         M & Less       ( Years 1 - 3)
     (Years 1 - 3)    (Years 1 - 3)      (EIAQ0T)
      (EIAHQ0)         (EIAHQ0)
                                         All Fund
       All Fund         All Fund       Options Age
     Options Age      Options Age      Last Birthday
     Last Birthday    Last Birthday       0 - 79
        0 - 79           80 - 85


       7.000%           3.500%           1.250%            None




   OM Index-Safety 10 ™ w/Trail (EIAH0P) All States Except TX and WA
      Standard -       Standard -        Renewal
    Compensation     Compensation
    Option 1 With    Option 1 With
    PTO - $1 M &     PTO - $1 M &
    Less (Years 1    Less (Years 1
    - 3) (EIAH0P)    - 3) (EIAH0P)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       4.350%           2.175%             None




                                                                       Page 2 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OM Index-Safety 10 - TX and WA Only
       Standard         Standard        Standard -       Standard -     Commission      Renewal
    Compensation     Compensation     Compensation     Compensation      Option 2 -
    Option 1 - $1    Option 1 - $1    Option 1 With    Option 1 With   1.00% Trail -
       M & Less         M & Less      PTO - $1 M &     PTO - $1 M &    ( Years 1 - 3)
     (Years 1 - 3)    (Years 1 - 3)   Less (Years 1    Less (Years 1     (EIAQ0T)
      (EIAHQ0)         (EIAHQ0)       - 3) (EIAH0P)    - 3) (EIAH0P)     Age 0-79
       Age 0-79        Age 80-85         Age 0-79        Age 80-85


       5.250%           2.625%           2.850%           1.425%         1.100%           None


   OMIndex-Accelerator 10 ™ All States Except TX and WA (EIAV10)
       Standard         Standard         Renewal
    Compensation     Compensation
       (EIAV10)         (EIAV10)
     (Years 1 - 3)    (Years 1 - 3)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       8.000%           4.000%            None

   OMIndex-Accelerator 10 ™ Applies to TX and WA Only (EIAV10)
       Standard         Standard         Renewal
    Compensation     Compensation
       (EIAV10)         (EIAV10)
     (Years 1 - 3)    (Years 1 - 3)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       6.750%           3.375%            None

   OMIndex-Accelerator 7 ™ (EIAV07)
       Standard         Standard         Renewal
    Compensation     Compensation
       (EIAV07)         (EIAV07)
     (Years 1 - 3)    (Years 1 - 3)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       5.000%           2.500%            None




                                                                       Page 3 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OMIndex-Escalator 10 ™
   All States Except AK, CT, MN, TX and UT
   (EIAF10)
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       6.500%           3.250%            None


   OMIndex-Escalator 10 ™
   Applies to AK, CT, MN, TX and UT ONLY
   (EIAF10)
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       5.500%           2.750%            None


   OMIndex-Escalator 10 ™ w/Trail
   All States Except AK, CT, MN, and UT
   (EIAF0P)
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       4.200%           2.100%            None


   OMIndex-Escalator 6 ™ (EIAF06)
       Issue Age        Issue Age        Renewal
     Last Birthday    Last Birthday
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       4.000%           2.000%            None


   OMIndex-Escalator 6 ™ w/Trail (EIAF6P)
       Issue Age        Issue Age        Renewal
     Last Birthday    Last Birthday
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       1.550%           0.775%            None


   OMIndex-Escalator 8 ™ (Flex Premium) w/Trail (EIAF8P)
   All States Except AK, CT, MN, TX, UT, WA and OR
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       3.350%           1.675%            None




                                                                       Page 4 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OMIndex-Escalator 8 ™
   All States Except AK, CT, MN, TX and UT
   (EIAF08)
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       5.500%           2.750%            None


   OMIndex-Escalator 8 ™
   Applies to AK, CT, MN, TX and UT ONLY
   (EIAF08)
       Issue Age        Issue Age        Renewal
          0-79            80-85
      All Options      All Options
      (Years 1-3)      (Years 1-3)

       4.500%           2.250%            None


   OMIndex-Safety 7 ™ (All States Except CT, MA, MN, TX, UT and WA)
      Standard -       Standard -     Compensation        Renewal
    Compensation     Compensation        Option 2 -
       Option 1         Option 1        1.00% Trail
    (EIAHQ7) $1M     (EIAHQ7) $1M        (EIAQ7T)
    & Less (Years    & Less (Years     (Years 1 - 3)
        1 - 3)           1 - 3)
                                         All Fund
       All Fund         All Fund       Options Age
     Options Age      Options Age      Last Birthday
     Last Birthday    Last Birthday       0 - 79
        0 - 79           80 - 85


       5.500%           2.750%           0.900%            None


   OMIndex-Safety 7 ™ (Applies to CT, MA, MN, TX, UT and WA Only)
      Standard -       Standard -     Compensation        Renewal
    Compensation     Compensation        Option 2 -
       Option 1         Option 1        0.75% Trail
    (EIAHQ7) $1M     (EIAHQ7) $1M        (EIAQ7T)
    & Less (Years    & Less (Years     (Years 1 - 3)
        1 - 3)           1 - 3)
                                         All Fund
       All Fund         All Fund       Options Age
     Options Age      Options Age      Last Birthday
     Last Birthday    Last Birthday       0 - 79
        0 - 79           80 - 85


       4.350%           2.175%           0.900%            None




                                                                       Page 5 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OMIndex-Safety 7 ™ w/Trail
   All States Except CT, MN, TX, UT, and WA
   (EIAH7P)
      Standard -       Standard -        Renewal
    Compensation     Compensation
    Option 1 With    Option 1 With
    Trail (EIAH7P)   Trail (EIAH7P)
     $1 M & Less      $1 M & Less
     (Years 1 - 3)    (Years 1 - 3)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       3.800%           1.900%            None


   OMIndex-Safety 7 ™ w/Trail
   Applies to CT, MN, TX, UT, and WA ONLY
   (EIAH7P)
      Standard -       Standard -        Renewal
    Compensation     Compensation
    Option 1 With    Option 1 With
    Trail (EIAH7P)   Trail (EIAH7P)
     $1 M & Less      $1 M & Less
     (Years 1 - 3)    (Years 1 - 3)

       All Fund         All Fund
     Options Age      Options Age
     Last Birthday    Last Birthday
        0 - 79           80 - 85


       2.650%           1.325%            None

   OMIndex-Spectrum 9 ™ (EIAT9C) Applies to MA, TX, WA & CT Only
        Standard         Standard        Renewal
     Comp Option      Comp Option
       1 $1M and        1 $1M and
     less All Fund    less All Fund
         Options          Options
        (EIAT9C)         (EIAT9C)
        Age 0-79        Age 80-85


       7.250%           3.625%            None


   OMIndex-Spectrum 9 ™ (EIAT9P) Applies to MA, TX, WA, CT, AK & MN Only
      Standard         Standard          Renewal
    Comp Option      Comp Option
    1 w/ PTO $1M     1 w/ PTO $1M
     and less All     and less All
    Fund Options     Fund Options
      (EIAT9P)         (EIAT9P)
      Age 0-79         Age 80-85


       5.250%           2.625%            None




                                                                       Page 6 of 7 — Retrieved 6/2/2010
OM Financial Life Insurance Company
R7 Street ANNUITY COMPENSATION SCHEDULE
The Following are Authorized Contracts and the compensation payable:




   OMIndex-Spectrum 9 â„¢ Applies to All States Except MA, TX, WA & CT (EIAT9C)
        Standard             Standard             Renewal
     Comp Option          Comp Option
       1 $1M and            1 $1M and
     less All Fund        less All Fund
         Options              Options
        (EIAT9C)             (EIAT9C)
        Age 0-79            Age 80-85


         9.000%               4.500%                None


   OMIndex-Spectrum 9 with PTO All States Except MA, TX, WA, CT, MN, & AK (EIAT9P)
       Standard             Standard              Renewal
     Comp Option          Comp Option
     1 w/ PTO $1M         1 w/ PTO $1M
      and less All         and less All
     Fund Options         Fund Options
       (EIAT9P)             (EIAT9P)
       Age 0-79             Age 80-85


         6.750%               3.375%                None


   ***Medicaid SPIA-Balloon + Level Benefit Payout Periods-Commissions will be paid based on the Benefit Payout period in whole years. Example: 2yrs 8 months will be calculated using the 2 year Benefit Payout
   Period.

   BASIC COMMISSIONS - Basic Commissions on Authorized Contracts listed below shall be payable in accordance with this Compensation Schedule. Basic Commissions are expressed as percentages of
   premiums received and accepted by the Company subject to the other provisions herein contained based on the policy effective date. Basic Commissions on additional policies and riders hereafter offered by the
   Company shall be payable at rates to be furnished by the Company. Any policies in force at the time this Compensation Schedule becomes effective shall be subject to the commission and commission
   chargeback provisions set forth in the Compensation Schedule applicable at the time such policies were issued. Commissions shall not be paid on any premiums waived or paid by the Company. This schedule
   is subject to change at any time by the Company.

   LARGE DEFERRED ANNUITY CASES - Traditional Fixed and Multi Year Guarantee Annuities (MYGA)- A large case is one in which the total first year premium is in excess of $600,000. A commission
   reduction of 50 basis points for any policy(s) issued on the same client in the same year for which the total first year premium in aggregate exceeds $600,000 will be made retroactive to the first dollar of premium
   (reduction is on the entire amount). Subsequent premiums may result in a chargeback if it causes the total premium to exceed $600,000.Indexed Annuities - For all Indexed Annuities, premiums are accepted up
   to and including $1,000,000 with no prior Home Office approval or reduction in commission. OMFN reserves the right to refuse to accept premiums in excess of $1,000,000 or choose a specific compensation
   option.

   COMMISSION FOR INTERNAL REPLACEMENTS - New policies issued by the Company as a result of internal replacement of existing policies will be compensated at a reduced rate set by the Company. The
   concurrent termination of one policy and issue of another will be treated as a replacement. Similarly, cash values paid to policyholders and subsequently returned for application to newly issued policies will be
   treated as if they were transferred directly and compensation will be adjusted accordingly. Policy values applied towards premium will not receive commission.

   COMMISSION CHARGEBACK â “ First year commissions on annuities unless otherwise indicated will be charged back at the rate of 100% on full surrenders, and partial surrenders which exceed the free
   amount (if any) or MRD, during the first twelve policy months and at the rate of 50% during the second twelve policy months. HeritageMaster (Single Premium Equity Indexed Universal Life) - chargeback on
   surrender is 100% during the first twelve policy months, at the rate of 50% during the second twelve policy months. Transition Safeguard (Single Premium Life) - 100% chargeback on policies not taken.

   ADDITIONAL - First year commissions will be charged back for: Any policy which is considered a "not taken"; Any policy which is not issued by the company, or if already issued, is rescinded; Any situation in
   which the producer fails to conform to applicable state regulations and /or company policies and procedures; Any situation in which the producer fails to reasonably cooperate with the company.

   CHARGEBACKS ON EARLY ANNUITIZATIONS (Applies to both traditional annuitization and annuitization under OM Safeguard): * If the annuitization of the Deferred Contract is within the commission
   chargeback period, 100% commission will be chargeback * If the annuitization is after the commission chargeback period, there is no chargeback.

   COMMISSIONS ON ANNUITIZATION OF DEFERRED ANNUITIES (Applies to both traditional annuitization and annuitization under OM Safeguard): Commissions on Annuitization from a Deferred Contract that
   was issued 1/1/2010 or forward: * No additional Compensation will be paid Commissions on Annuitization from a Deferred Contract that was issued prior to 1/1/2010: * Will be paid Full SPIA commissions on
   annuitizations during the commission chargeback period and after the policy surrender penalty period expires. * For annuities with repeating surrender charge periods, Full SPIA commissions will be paid on
   annuitizations which occur at any time after the second interest rate guarantee period.

   DEATH OF OWNER â “ There are no chargebacks on death of a policyowner.

   TRAIL COMPENSATION - Trail compensation is offered at issue only and cannot be changed after issue (no reissues). The trail compensation will be generated based on the percent indicated per year for the
   life of the contract unless otherwise indicated. The trail compensation will be based on the account value and will be paid quarterly (end of the quarter) beginning after the first policy year. The trail compensation
   will be paid to the writing agent level only for the life of the contract unless indicated on the matrix otherwise. The trail compensation is not available over age 79.

  PTO - Performance Trail Option

  This Compensation Schedule is effective as of the later of March 01, 2010 or the date the referenced products are approved by the Company for sale in the state(s) in which you do business.




  R7 Street - (Effective 3/1/2010)




                                                                                          Page 7 of 7 — Retrieved 6/2/2010
        Producer/Agency Form
                                  Producer                            OM Financial Life Insurance Company
                                  Agency                              OM Financial Life Insurance Company of New York

                                                                                 Instructions:
Step 1. Complete, Sign and Date this Form. If you are a corporate principal, complete a separate form for the corporation. Forward the form(s) to your appointing agency.
Step 2. Appointing General Agencies, please complete the bottom portion of the Form authorizing the hierarchy set up and compensation.
Step 3. Once contracted and you have been given access to SalesLink, you will be asked to sign additional Agreements via an electronic signature.


MGA Name: _________________________________________________________________ MGA Number _______________________________
               The Annuity Shop LLC
MGA Address: ___________________________________________________________________________________________________________
                 2536 Countryside Blvd STE-410
                                                                                       FL
City: _______________________________________________________________________ State: _____________ Zip Code: ________________
        Clearwater                                                                                           33763
          727-791-7838
Phone: _______________________________________________________ Fax: ______________________________________________________
                                                                       727-791-7588
………………………………………………………………………………………………………………………………………………
Producer/Agency Information                                                           5. Have you ever been alleged to have engaged in any fraud?
Producer/Agency Name: _____________________________________                               Yes  No
Residence Address: _________________________________________                          6. Have you ever been found to have engaged in any fraud?
City: _______________________ State: ______ Zip: ______________                           Yes  No
Residence Phone: __________________________________________
                                                                                      7. Have you ever been convicted of any crime?
Cell Phone: ________________________________________________                              Yes  No
Business Address: __________________________________________
City: _______________________ State: ______ Zip: ______________                       8. Have you ever been barred, fined or disciplined by any
                                                                                         insurance, securities or other regulator in any jurisdiction?
Business Phone: ____________________ Fax: ___________________
                                                                                          Yes  No
e-mail address: _____________________________________________
Preferred method of contact:  e-mail  Phone  Fax                                   9. Have you ever had your license to offer or sell insurance products
Date of Birth: ______________________________________________                            or securities suspended or revoked in any jurisdiction?
                                                                                          Yes  No
Social Security Number: _____________________________________
Corporation TIN Number: ____________________________________                          10. Do you hold a current Certificate of Continuing Education for
Gender:  M  F  Agency                                                                  California and/or Iowa?  Yes (Please attach a copy)  No
Language(s) spoken other than English: _______________________                        11. Have you taken the AML training course?  Yes
Resident State License No.: __________________________________                             No (If not, you are required to complete the LIMRA AML
                                                                                          training course and will be entered into the LIMRA database.)
Additional States in which you wish to be appointed
and License Numbers for each:                                                         If the Answer to any question from 1-9 above is yes, please attach
____________________________ ____________________________                             an explanation. Additional information such as supporting docu-
Non- Resident State                License Number                                     ments may be required.
____________________________ ____________________________                             By signing below, I: (i) certify that all of the information provided on this
Non- Resident State                License Number                                     form is true and correct and I acknowledge that my failure to provide
____________________________ ____________________________                             truthful and accurate information is a valid basis for the immediate
Non- Resident State                License Number                                     termination of my relationship with OM Financial Life Insurance Com-
                                                                                      pany and/or OM Financial Life Insurance Company of New York (the
1. Have you ever filed for bankruptcy?  Yes               No                        “Company” in reference to either or both, as applicable), for cause; (ii)
2. Have you ever been the subject of any complaint related to the                     authorize the Company to conduct an investigation of my background
                                                                                      and to disclose the results of any such investigation to the Agency(ies)
   solicitation or sale of any insurance product(s), securities or any
                                                                                      with which I am or become affiliated; and (iii) acknowledge that I have
   financial product or service, in any jurisdiction?                                 received, read, and will comply with the Company’s Code of Ethical
    Yes  No                                                                         Conduct and Market Conduct Guide, and that I have received, read,
3. Have you ever been the subject of any investigation or proceeding                  and agree to be bound by the terms of the Company’s Producer/Agency
   by any insurance or securities regulator in any jurisdiction?                      Agreement (each as amended from time-to-time). I understand that I
    Yes  No                                                                         can access all of these documents on SalesLink.

4. Have you ever been accused of or charged with any improper                         Signature of Producer
   conduct related to the solicitation or sale of any insurance                       or Principal of Agency: ______________________________________
   product(s), securities or any financial product or service?                                                              Date: __________________________
    Yes  No
………………………………………………………………………………………………………………………………………………
  To be completed by the Appointing Agency
  Name of Agency: __________________________________________________________________ AGA Code: ______________
                      The Annuity Shop LLC                                                      268521
  Approved compensation level/contract type(s): _________________________________________________________________
  Signature of Authorized Agent: __________________________________________________________ Date: _______________
  Contact Agency by:  Fax  e-mail
 OMAD 6151 (03-2008)                                                                                                                                    Rev. 05-2008
Form                                   W-9                                          Request for Taxpayer                                                                     Give form to the
(Rev. January 2002)                                                                                                                                                          requester. Do not
Department of the Treasury
                                                                          Identification Number and Certification                                                            send to the IRS.
Internal Revenue Service
                                       Name
See Specific Instructions on page 2.




                                       Business name, if different from above
           Print or type




                                                                     Individual/                                                                                               Exempt from backup
                                       Check appropriate box:        Sole proprietor            Corporation         Partnership       Other                                    withholding
                                       Address (number, street, and apt. or suite no.)                                                           Requester’s name and address (optional)


                                       City, state, and ZIP code


                                       List account number(s) here (optional)


      Part I                                  Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).                                                          Social security number
However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on                                                                   –          –
page 2. 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 2.                                                                                                                                               or
Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number                                                       Employer identification number
to enter.                                                                                                                                                          –
      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. person (including a U.S. resident alien).
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 2.)

Sign                                       Signature of
Here                                       U.S. person                                                                                          Date

Purpose of Form                                                                          What is backup withholding? Persons making                 5. You do not certify to the requester that you
                                                                                         certain payments to you must under certain               are not subject to backup withholding under 4
A person who is required to file an information                                          conditions withhold and pay to the IRS 30% of            above (for reportable interest and dividend
return with the IRS must get your correct                                                such payments after December 31, 2001 (29%               accounts opened after 1983 only).
taxpayer identification number (TIN) to report, for                                      after December 31, 2003). This is called “backup
example, income paid to you, real estate                                                                                                             Certain payees and payments are exempt
                                                                                         withholding.” Payments that may be subject to            from backup withholding. See the instructions on
transactions, mortgage interest you paid,                                                backup withholding include interest, dividends,
acquisition or abandonment of secured property,                                                                                                   page 2 and the separate Instructions for the
                                                                                         broker and barter exchange transactions, rents,          Requester of Form W-9.
cancellation of debt, or contributions you made                                          royalties, nonemployee pay, and certain
to an IRA.                                                                               payments from fishing boat operators. Real               Penalties
   Use Form W-9 only if you are a U.S. person                                            estate transactions are not subject to backup
(including a resident alien), to give your correct                                       withholding.                                             Failure to furnish TIN. If you fail to furnish your
TIN to the person requesting it (the requester)                                                                                                   correct TIN to a requester, you are subject to a
                                                                                           You will not be subject to backup withholding          penalty of $50 for each such failure unless your
and, when applicable, to:                                                                on payments you receive if you give the                  failure is due to reasonable cause and not to
  1. Certify the TIN you are giving is correct (or                                       requester your correct TIN, make the proper              willful neglect.
you are waiting for a number to be issued),                                              certifications, and report all your taxable interest
                                                                                         and dividends on your tax return.                        Civil penalty for false information with respect
  2. Certify you are not subject to backup                                                                                                        to withholding. If you make a false statement
withholding, or                                                                          Payments you receive will be subject to                  with no reasonable basis that results in no
                                                                                         backup withholding if:                                   backup withholding, you are subject to a $500
  3. Claim exemption from backup withholding if
you are a U.S. exempt payee.                                                               1. You do not furnish your TIN to the                  penalty.
                                                                                         requester, or                                            Criminal penalty for falsifying information.
  If you are a foreign person, use the
appropriate Form W-8. See Pub. 515,                                                         2. You do not certify your TIN when required          Willfully falsifying certifications or affirmations
Withholding of Tax on Nonresident Aliens and                                             (see the Part II instructions on page 2 for              may subject you to criminal penalties including
Foreign Entities.                                                                        details), or                                             fines and/or imprisonment.
                                                                                            3. The IRS tells the requester that you               Misuse of TINs. If the requester discloses or
Note: If a requester gives you a form other than
                                                                                         furnished an incorrect TIN, or                           uses TINs in violation of Federal law, the
Form W-9 to request your TIN, you must use the
                                                                                                                                                  requester may be subject to civil and criminal
requester’s form if it is substantially similar to this                                     4. The IRS tells you that you are subject to          penalties.
Form W-9.                                                                                backup withholding because you did not report
                                                                                         all your interest and dividends on your tax return
                                                                                         (for reportable interest and dividends only), or

                                                                                                           Cat. No. 10231X                                                  Form   W-9     (Rev. 1-2002)
Form W-9 (Rev. 1-2002)                                                                                                                                         Page      2
                                                      Application for IRS Individual Taxpayer           Privacy Act Notice
Specific Instructions                                 Identification Number, to apply for an ITIN, or
Name. If you are an individual, you must              Form SS-4, Application for Employer               Section 6109 of the Internal Revenue Code
generally enter the name shown on your                Identification Number, to apply for an EIN.       requires you to give your correct TIN to
social security card. However, if you have            You can get Forms W-7 and SS-4 from the           persons who must file information returns
changed your last name, for instance, due to          IRS by calling 1-800-TAX-FORM                     with the IRS to report interest, dividends, and
marriage without informing the Social Security        (1-800-829-3676) or from the IRS Web Site at      certain other income paid to you, mortgage
Administration of the name change, enter              www.irs.gov.                                      interest you paid, the acquisition or
your first name, the last name shown on your                                                            abandonment of secured property,
                                                         If you are asked to complete Form W-9 but      cancellation of debt, or contributions you
social security card, and your new last name.         do not have a TIN, write “Applied For” in the     made to an IRA or Archer MSA. The IRS uses
   If the account is in joint names, list first and   space for the TIN, sign and date the form,        the numbers for identification purposes and
then circle the name of the person or entity          and give it to the requester. For interest and    to help verify the accuracy of your tax return.
whose number you enter in Part I of the form.         dividend payments, and certain payments           The IRS may also provide this information to
   Sole proprietor. Enter your individual             made with respect to readily tradable             the Department of Justice for civil and
name as shown on your social security card            instruments, generally you will have 60 days      criminal litigation, and to cities, states, and
on the “Name” line. You may enter your                to get a TIN and give it to the requester         the District of Columbia to carry out their tax
business, trade, or “doing business as (DBA)”         before you are subject to backup withholding      laws.
name on the “Business name” line.                     on payments. The 60-day rule does not apply
                                                      to other types of payments. You will be              You must provide your TIN whether or not
   Limited liability company (LLC). If you are                                                          you are required to file a tax return. Payers
a single-member LLC (including a foreign LLC          subject to backup withholding on all such
                                                      payments until you provide your TIN to the        must generally withhold 30% of taxable
with a domestic owner) that is disregarded as                                                           interest, dividend, and certain other payments
an entity separate from its owner under               requester.
                                                                                                        to a payee who does not give a TIN to a
Treasury regulations section 301.7701-3,              Note: Writing “Applied For” means that you        payer. Certain penalties may also apply.
enter the owner’s name on the “Name”                  have already applied for a TIN or that you
                                                      intend to apply for one soon.
line. Enter the LLC’s name on the “Business
name” line.                                           Caution: A disregarded domestic entity that
                                                                                                        What Name and Number To
   Other entities. Enter your business name           has a foreign owner must use the appropriate      Give the Requester
as shown on required Federal tax documents            Form W-8.
                                                                                                        For this type of account: Give name and SSN of:
on the “Name” line. This name should match
the name shown on the charter or other legal          Part II—Certification                                 1. Individual                  The individual
document creating the entity. You may enter           To establish to the withholding agent that you        2. Two or more                 The actual owner of the
any business, trade, or DBA name on the               are a U.S. person, or resident alien, sign Form          individuals (joint          account or, if combined
“Business name” line.                                 W-9. You may be requested to sign by the                 account)                    funds, the first individual
                                                                                                                                           on the account 1
   Exempt from backup withholding. If you             withholding agent even if items 1, 3, and 5
                                                                                                            3. Custodian account of        The minor 2
are exempt, enter your name as described              below indicate otherwise.                                a minor (Uniform Gift
above, then check the “Exempt from backup                For a joint account, only the person whose            to Minors Act)
withholding” box in the line following the            TIN is shown in Part I should sign (when              4. a. The usual                The grantor-trustee     1

business name, sign and date the form.                required). Exempt recipients, see Exempt                    revocable savings
                                                      from backup withholding above.                              trust (grantor is
   Individuals (including sole proprietors) are                                                                   also trustee)
not exempt from backup withholding.                   Signature requirements. Complete the                     b. So-called trust          The actual owner    1
Corporations are exempt from backup                   certification as indicated in 1 through 5                   account that is not
withholding for certain payments, such as             below.                                                      a legal or valid trust
interest and dividends. For more information             1. Interest, dividend, and barter                        under state law
on exempt payees, see the Instructions for            exchange accounts opened before 1984                  5. Sole proprietorship         The owner   3

the Requester of Form W-9.                            and broker accounts considered active
   If you are a nonresident alien or a foreign        during 1983. You must give your correct TIN,      For this type of account: Give name and EIN of:
entity not subject to backup withholding, give        but you do not have to sign the certification.     6. Sole proprietorship            The owner 3
the requester the appropriate completed                  2. Interest, dividend, broker, and barter       7. A valid trust, estate, or      Legal entity 4
Form W-8.                                             exchange accounts opened after 1983 and               pension trust
Note: If you are exempt from backup                   broker accounts considered inactive during         8. Corporate                      The corporation
withholding, you should still complete this           1983. You must sign the certification or           9. Association, club,             The organization
form to avoid possible erroneous backup               backup withholding will apply. If you are             religious, charitable,
                                                                                                            educational, or other
withholding.                                          subject to backup withholding and you are             tax-exempt
                                                      merely providing your correct TIN to the              organization
Part I—Taxpayer Identification                        requester, you must cross out item 2 in the       10. Partnership                    The partnership
Number (TIN)                                          certification before signing the form.            11. A broker or registered         The broker or nominee
Enter your TIN in the appropriate box.                   3. Real estate transactions. You must              nominee
                                                      sign the certification. You may cross out         12. Account with the               The public entity
   If you are a resident alien and you do not                                                               Department of
have and are not eligible to get an SSN, your         item 2 of the certification.
                                                                                                            Agriculture in the name
TIN is your IRS individual taxpayer                      4. Other payments. You must give your              of a public entity (such
identification number (ITIN). Enter it in the         correct TIN, but you do not have to sign the          as a state or local
social security number box. If you do not             certification unless you have been notified           government, school
                                                                                                            district, or prison) that
have an ITIN, see How to get a TIN below.             that you have previously given an incorrect           receives agricultural
   If you are a sole proprietor and you have          TIN. “Other payments” include payments                program payments
an EIN, you may enter either your SSN or              made in the course of the requester’s trade
EIN. However, the IRS prefers that you use            or business for rents, royalties, goods (other    1
                                                                                                          List first and circle the name of the person whose
your SSN.                                             than bills for merchandise), medical and          number you furnish. If only one person on a joint
                                                      health care services (including payments to       account has an SSN, that person’s number must be
   If you are an LLC that is disregarded as
                                                      corporations), payments to a nonemployee for      furnished.
an entity separate from its owner (see
                                                      services, payments to certain fishing boat        2
Limited liability company (LLC) above), and                                                                 Circle the minor’s name and furnish the minor’s SSN.
                                                      crew members and fishermen, and gross
are owned by an individual, enter your SSN                                                              3
                                                                                                         You must show your individual name, but you may
                                                      proceeds paid to attorneys (including
(or “pre-LLC” EIN, if desired). If the owner of                                                         also enter your business or “DBA” name. You may use
                                                      payments to corporations).
a disregarded LLC is a corporation,                                                                     either your SSN or EIN (if you have one).
partnership, etc., enter the owner’s EIN.                5. Mortgage interest paid by you,              4
                                                                                                         List first and circle the name of the legal trust, estate,
                                                      acquisition or abandonment of secured             or pension trust. (Do not furnish the TIN of the personal
Note: See the chart on this page for further
                                                      property, cancellation of debt, qualified         representative or trustee unless the legal entity itself is
clarification of name and TIN combinations.
                                                      tuition program payments (under section           not designated in the account title.)
How to get a TIN. If you do not have a TIN,           529), IRA or Archer MSA contributions or
apply for one immediately. To apply for an                                                              Note: If no name is circled when more than
                                                      distributions, and pension distributions.         one name is listed, the number will be
SSN, get Form SS-5, Application for a Social          You must give your correct TIN, but you do
Security Card, from your local Social Security                                                          considered to be that of the first name listed.
                                                      not have to sign the certification.
Administration office. Get Form W-7,

								
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