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    1. Complete all portions of Agent Contract and Agent Agreement 
       that apply (if any questions are answered ‘yes’, please provide a 
       written explanation to help speed up your contract through the 

    2. Direct Deposit Information must be completed and a VOIDED 
       CHECK must be attached 

    3. Include current State License(s)  

If faxing or emailing your contract, please return the pages that you 
actually filled in and signed plus the commission schedule(s). 

               Return completed contracts to: 
                       Complete Solutions, Inc. 
                            75 N. Dixie Drive 
                         Vandalia, Ohio 45377 
                          Fax to 937.898.3048 
                   Email Barb at barbw@csi‐ 
If you have any questions, please call us at 1.866.866.7951 

                                                        AgtChklst‐NoE&O 022811 

F I NANCIAL              O
                  Unlty FInanCla I LOf e Insurance Company
                    °         °
                  Privacy Policy for Agents

                                             Privacy Policy

        At Unity Financial Life Insurance Company, we are committed to
        safeguarding your privacy and keeping your personal information secure.

        We collect nonpublic personal fmancial and health information about you
        from the following sources:

              •    Information we receive from you on applications or other forms

              •    Information about your transactions with us, or others; and

              •    Infonnation we receive from an agent background check pursuant to
                  the authorization you have given us.

        We do not disclose any nonpublic personal financial or health information
        about our customers or former customers to anyone, except as permitted by

        We restrict access to nonpublic personal financial and health information
        about you to those employees and company agents who need to know that
        information to provide products or services to you. We maintain physical,
        electronic and procedural safeguards that comply with federal and state
        regulations to guard your nonpublic personal financial and health

                                   Unity Financial Lifl' Insnrancl' Company
                                  PO Box 625700 Cincinnati, OR 45262-5700
                     Phone: (513) 247-071 1 Toll Free: (877) 523-323 1 Fax: (5 13) 247-5040
Agt'nt to bt' Appoiott'd : _ _ _ _ _ _ _ _ _ _ _ _ __

RepOit s to: ____________________ Level:

RepOit s to: ____________________ Level:

RepOit s to: ____________________ Level:

RepOit s to: ____________________ Level:

Appointment M aterials Checklist:

         GA Agreement; signed by Appointee and everyone to whom they repOit

         Application for Agent Contract

         Signed Authorization to Release Infol1uation (FCRA fOl1u)

         Copy of CUlTent insurance license, OR if not cUlTently licensed, state licensing

         Signed Connuission Advancing Agreement

         Connuission Direct Deposit Fonn (if applicable)

         Signed Conmnssion Assiglmlent (if applicable)

         Signt'd W-9 (mandatOlY)

         Signed Conmnssion Schedule

         Other (describe:                                                                    )

I hal't' r t'l'it'wt'd this appointmt'llt I't'qut'st and it appt'al'S to bt' complt'tt' and corl't'et.

MGAlASD Signatllrt':

UELI C H eadquarters Use:                                     Agency Number: ______

Agent Writing Number: _ _ _ _ __                  Conmnssion Level Number: ______

Advancing?      YES     NO               If Yes, Reserves = _ _% to $ _ _ _ _ _ __

Commissions Assigned?          NO        YES, to _ _ _ _ _ _ _ _ _ _ _ __

Appointment Completed By: _ _ _ _ _ _ _ _ _ _ _ Date: _ _ __

Please attac h a copy ofyollr c urre nt licellsej or each state in which YOlIll'ish to be appointed. ljif is a Corporation or partnership
requesting appointment, please p rovide a copy ofthe comp lete license showing each afthe sublicensees. Please answer all questions:

PROSPECTIVE GENERAL AGENT: _ _ _ _ _ _ _ _ _ _ _ _ _ ss oc T" ID #

Male or Female         Date of B irth: _ _ _ _ __            Managing Gen eral Agent!Agency: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

By your signanu"e below. you certify that you have provided your correct taxpayer idelllificatiollillunber and thai you are not subject to
bad.. lp withholding .

                          (Please print clearlv and orovide b oth Residence and Business Addresses)
                         Residl'DCe Ad dnss                                         Business Address

                                                                         E-mail:                               Cellular:
 Phone :                                                                 Phone:                                Fax :

For policy issue or client service questions, please contact me by:          Tel('phone         Fax           [ntel'Det             A ny

Please send my commissions and related infonnation to my:             Residence              Business

                                                             STATE LICENSES
               State                           Reference #                TYDl" ofLic('nse                           Lines of Business

Do you hold a current Ftmeral Director' s License for the state in which you intend to sell life insurance?                        No
Are you a U.S. Citizen?          Yes         No

                                             e u g,               I        r PAST FIVE ve ,     ,~

                                                                          , dat.,
 Name or ,
                                                   From                 To
                                                   From                 To

Criminal Histol-Y: Federal Law prohibits anyone who has been convicted of a felony involving dishonesty or a breach of tIllSt, to
participate in the business of insurance. Have you (or, if a corporation, any of the sublicensees) ever been convicted of any Clime (including
DUI) other than a minor traffic offense? If yes, please provide details, including date, jlllisdiction, charge and sentence. _ y ., _ No

Financial I nfonoation: Have you ever llSed any other nallle{s)? If so, please provide name(s): __~_ _ _= _________
Are you presently indebted to any insurance company, its managers or managing general agents?     Yes   No
Have you filed for bankmptcy within the past seven years? :     Y('s       No

Datl": _ _ _ _ _ _ _ _ __                     Signatur(': _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _                       <::::::!!!!iil
                   UNITY FINAt,'CIAL LIFE Ii \,SURANCE COMPAi'o'Y
                    PO Box 625700 Cincimlati, OH 45262-5700

Gelleral Agellt's Agreemellt
Between Unity Financial Life Insurance Company ("the Company") and _________________________ of

   1.   Appointm('ut. TIle Company hereby appoints the General Agent to conduct an insurance agency to solicit applications for life insurance
        and ailluities, both individual and group, to be submitted to the Company for approval or rejection and to collect and remit to the
        Company the first premillllS on such insurance, to deliver policies when the tetlllS and conditions govetlling such delivery shall have been
        complied with, and to perfonn such other duties as may be requir ed by the Company. TIle General Agent shall have the right to appoint
        agents, with the approval of the Company, on the foOllS fiunished by the Company, one copy being filed with the Company. TIle
        General Agent shall be responsible to the Company for all matters entmsted to him and for his acts and conduct relating to the business
        of the Company, and agrees to hold the company haImless from and against any and all clainlS of all agents and persons employed by

   2.   R ('lationship. Tins agreement shall not be constmed to create the relationslnp of employer aIld employee between the General Agent
        and the Company. The General Agent is het·eby constituted and shall in all respects continue to be an independent contractor. TIle
        General Agent shall be free to exercise his O"wn judgment as to the persons he will solicit for insurance.

   3.   Rnl('s . The Getleral Agent shall COnf0I111 to all the mles and regulations of the COmpaIlY, now or hereafter to become in force, which
        shall constitute a paI1 of tins Agreement.

   4.   Funds. TIle General Agent shall illullediately rennt to the Company all fund s received or collected on behalf of the COmpaIlY.

   5.   TIle General Agent shall have no power or authority to do any of the following:

            a.   Represent that he is an employee, associate, joint venture or officer of the Company.
            b.   Change or waive aIly of the tenns, conditions or rates set f0l1h in promotional materials, or any advertisements, receipts,
                 contr acts, applications, or policies of the Company in any mlumer whatsoevet·.
            c.   Issue, print or circulate any advertisement, or sales material conceming the Company or any othet· company without obtaining
                 prior approval in writing from the Company.
            d    Bind the Company on any application for a policy of itlSUfaIICe or group certificate.
            e.   Extend the titne of payitlg any premiulll, or rebate or offer to rebate any part of a prellnum.
            f    Make any nnsrepresentation or itlcomplete comparison in order to induce policyholders of the Company or any other COmpaIlY
                 to convert, lapse, surrender or forfeit Ins itlSUfaIlce.
            g.   Exet·cise any authority on behalf of the General Agent or the Company other than that expressly conferred by this Agreement
                 lUlless authorized by the Company in writing.

   6.   Ind('bt('dnt'ss. The Company shall have the right to set off aIly debts owed by the General Agetlt to the COmpaIlY agaitlst any
        compensation due or which may become due the General Agent. In addition to such right of offset, the General Agent will pay on
        demand any amounts owed to the Company during or after the life of this contract, inciuditlg aIly collection costs itlculTed by the

   7.   Sub-Ag('ut Indt'bt('dnt'ss. If the General Agetlt has Sub-Agents for which the General Agetlt receives an oven"ide conmnssion, the
        Genet·al Agent guarantees the payment of any debit balance or othet· indebtedness itlculTed by such Sub-Agetlts. The General Agent will
        pay the Company on demand if the Company, in its judgment, is wlable to collect such balances Whetl due. If the General Agent pays
        the Company for a Sub-Agent's indebtedness, the COmpaIlY will assign its rights to such itldebtedness to the Genet·al Agetlt to the extetlt
        of the General Agent's payments to the Company.

   8.   L ('gal Proct'('dings. TIle General Agent shall have no authority to itlstinlte, prosecute or maitltaitl aIly legal proceedings in connection
        with any matter pertaitlitlg to the General Agent's or Company's busitless, except with the wr itten COilSent of the Company. In the event
        any legal process or notice is served on the General Agent itl a suit or proceeding agaitlstthe Company, the General Agent shall
        forthwith fonvard such process or notice to the Company by ovetllight delivery.

   9.   Chang(' or T('rmination. lhis agreement may be changed from time 10 time by written notice from the Company but no such cilange
        shall affec t conmnssions on aIly contract or policy issued prior to the effective date of the cilange. Either party may tenninate this
        Agreement al any time by giving the other party ten days' notice in wr ititlg. TIns Agreement shalltetllnnate forthwith on the death of the
        Genet·al Agent. Any compensation due to or indebtedness owed by the General Agent at Ins death or fallitlg due thet·eafter, wider this
        Agreement shall be paid to or by his executors or adnnnistr ators.
10. Termination for Caus('. If the General Agent shall willfully or knowingly (1) submit any false infonnation, or (2) conceal any material
    facts conceming the medical or personal history of any applicant or proposed Lnsmed, or (3) cmilliut fraud, or (4) withhold or conve11to
    his own use money or documents belonging to the Company, or (5) rewrite or cause to be rewritten with any other insurer any policy in
    force with the Company, whether or not such policy had been written by the General Agent, without prior written notice to the
    Company, or (6) induce or attempt to induce. any General Agent or employee of the Company to leave its selvice or to cease soliciting
    or writing business for the Company or to decrease the volume of business so written, or (7) improperly induce, or attempt to induce,
    any policyholder of the Company to discontinue premium payments on this policy, or (8) fail to confonn to the mles and regulations of
    the Company, or (9) fail to comply with the laws and regulations of any state where the General Agent is appointed by the Company, or
    fail to main tain in good standing a license to sell insurance in such states or (10) violate any of the provisions or conditions of tlus
    Agreement, the Company shall tenninate this Agreement by written notice and all interest the General Agent may have in any
    cmilliussions and any other compensation lUlder this and previous agreements made with the Company or any of its agents shall be
    forfeited. Such tennination does not relieve the General Agent of any obligations to pay indebtedness owed at the time of tennination or

11 . Commissions. As compensation for production and setvices as General Agent, the General Agent shall be paid by the
     Company cOimnissions computed in accordance with the accompanying COimnission Schedules. TIle conUlussion schedules shall be
     subject to change by the Company at any time, such changes to be applicable to all policies issued after the effective date thereof.
     ConUlussions are not eal1led on policies which are renmled to the Company and voided. The Company will recover an amount equal to
     the conlllussions paid or advanced on any policy which, during the first policy year, ceases to be in force as a result of death, lapse,
     SUlTetlder, free look, or sillular eVetlt. TIle date of death is the actual date, not the reported date. Policies with a death benefit resulting
     from a nonforfeinlIe benefit do not count as in force. The company may recovet· COllUlussion payments at any time if the company voids
     or rescinds a policy and renUllS prellumn.

12. Renewal Commissions. If any policy written under tlus Agreement shall cease to be in force on a prelnium-paying basis for a period of
    ninety days, from the due date of the prelniUlll in default and be subsequently reinstated, the Genet·al Agent shall not be entitled to any
    further renewal conlllussions on such policy mLiess the policy is reinstated through Ius agency.

13. Commission Paym('nts and Rdunds. No COllUlussions shall be payable on any rejected application. Should a policy issued on an
    application secmed by the General Agent lapse and not be reinstated, the General Agent shall have no further intet·est of any kind in the
    policy unless it be reinstated tliiough the efforts of Ius agency while tlus agreement is in effect. Should the Company refund the prenumll
    for any reason, including but not linuted to cancellation and rescission, on any policy written on an application secmed by the Agent, he
    shall refrmd to the Company, if so instmcted, any and allmmues received by lum by reason of the payment of such prenulmlS.

14. Rep0l1ing ofSubsequ('nt Evt'nts. After the date of this contract, General Agent shall promptly notify Company if the General Agent is
    arrested for or convicted of any Ilusdemeanor or felony other than minor traffic vio lations or if General Agent files for bankmptcy, either
    personally or for any entity directly related to Ius or het· insmance business.

15. Limitations. TIle Company reserves the right, in its sole discretion and without liability to the General Agent, to disapprove any
    application for insurance subllutted to it by the General Agent or any agent or person lmder his supervision and to linut or restrict the
    amOlUlt of or plan of insmance it shall issue and to require a higher prellumn that than applied for.

16. Assignm('nt. TIlis Agreement is not transferable . No rights or interests lUlder tlus Agreemetlt shall be subj ect to assignment without the
    ·written consent of the General Agetlt and the Company.

17. 'Vaivt'r. The failure of the Company to enforce any provision of this Agreement or to insist upon strict compliance by the General Agent
    with any of the provisions shall not constinlte a waivet· of any of the rights or privileges of the Company lUldet· tlus Agreenlent and shall
    not be deemed to constinlte a COlD"Se of conduct or waiver as to any subsequent acts.

18. Entin' Agrt'emt'nt. TIlis Agreement shall supersede any prior Agreement bel\veenthe Company and the General Agent in relation to
    policies issued through the General Agent after the Agreetllent becomes effective. The foregoing, together with accompanying
    schedules, cOilStitutes the entire Agreemetlt between the parties.

19. Liability. Each shareholdet· or partner, if the General Agent is a corporation or pal1nership, personally and frilly guarantees the
    perfonnallce by the General Agent of evety conUlutment, covenant and lUldet1aking in this Agreement, provided such person or perSOIlS
    has signed this contract individually or on behalf of the General Agent.

                                                                                                   Sup(,l"Vising G('neral Agt'nt(s)

                        Gt'nt'ral Agent
                                                                                                      Managing Gt'neral Ag('nt

                                                                                                        For tile Company
                                         '                           '
                             UNITY FTh'Ai\'CIAL LIFE INSURANCE COMPAi ry
                             PO Box 625700 Cincitmati, OH 45262-5700

                                                          Agl't't'IDt'nt fol' Rest'rvt' Account

I hereby agree that Unity Financial Life Insurance Company ("the Company") reserve sums agaitlSt commissions to be eamed lUlder the
provisions of my General Agent's Agreement, and I agree that:

    1.   All conunissions paid are subject to potential chargebacks. I understand that any itldebtedness remaitling on the date my General Agent 's
         Agreement tel1uinates will become immediately payable itl full. Any itldebtedness that is incurred after tennination of my Agreement
         will be payable on demand.

    2.   Rt'ser ve F und: I understand that a Reselv e Fund will be created, whereitl a percentage of my conunissions will be held at the Company
         until a cap has been reached.

                                Initial Reselv e Fund                               Company
                                Percentage:                                         Approval:                %

                                In.itial Reselv e Fund    $3,000.00                 Company
                                Cap:                                                Approval:     $

    3.   Conmnssion charge-backs will be withdrawn from the Reserve Flmd fIrst. If the Reselv e Fund is itlsufficient, charge-backs will be
         taken from my next conmnssion check. I understand and agree Ihat the Reserve Fund percentage and/or cap amount may be changed al
         any litne by Ihe Company.

    4.   TIns Agreement may be tenninated al any titne for any reason withoul notice to me.

                        Date: _ _ _ __              Signed:                                       =
                                                              ----.==..,"";mru;.-------------- '--- ...
                                                                 Gi'ii'nI AgeIlt'. Signallft

                                      Print full name : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

                                                              Authorization Signatures

                               Supelv ising General Agent: ~ ~ ~ 6'OM9 Date: _ _ _ __

                               MGA: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ __

                               Chief Markeling Officer: _ _ _ _ _ _ _ _ _ _ _ _ Date :
                                          Cincinnati, Ohio

                         PRODUCER'S COMMISSION SCHEDULE

The Producer shall be entitled to receive commission at the rates shown 011 this schedule for
Group or Individual products with applications or emolhnent [onns dated on or after May 1,
2008 until f1ll1her notice. Payment of commission under this schedule shall be subject to all the
provisions of the General Agent's Agreement between the Company and the General Agent and
is subject to change as provided in the General Agent ' s Agreement.

                                        Single Premium
                           COli/missions expressed as a percentage of

                                     Client                Rate
                                   Issu(' A2l'
                                      1-65                  16.5
                                     66-70                 14.85
                                     71 -75                12.65
                                     76-80                 9.35
                                     81 -85                4.4
                                     86-90                 3.3
                                     91 -99                0.55

Commission Chargebacks:

      •    COIllmissions are not eamed 011 policies which are renlflled to the Company and
      •    The Company will recover an amount equal to the commissions paid or advanced on
           any policy which, during its [u·st policy year was sUlTendered for the policy cash
      •    If the insured dies prior to the first policy anniversalY the commission will be charged
           back 100%.
      •    If a policy is issued with an incolTect age and the COiTect age would have resulted in a
           lower commission, a partial chargeback will take place to result in the COlTect

I have read a1ld agree with the above:

                                                     -:;::. -Date: _ _ _ _ _ _ _ __
Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _---.:""''''''

Print Full Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Level 8T

                           PRODUCER'S CON,IN,IISSION

The Producer shallbe entitledto receiveconunission the ratesshorvn this schedule
                                                 at                on               for
Groupor Lrdividualproductswith applications eruolhnent
                                            or            forus datedon or atterMay I,
2008uutil hutheruotice. Payment coulnissionrurder
                                  of                 this schedule               to
                                                                  shallbe subject all the
provisions the General
          of            Asent's Agreeurent behveen Company
                                                   the           and the GeneralAgentand
is subject change providedin the General
         to        as                       Agent'sApreemelt.

                             Cotttrttissions        as
                                           etpres,sed a percentageof

                                       Cllent                   Rnte
                                       50-60                    | 5.!

                                       6l-65                    I 3.75
                                       66-70                    15./.

                                       7t-75                    9.9
                                       76-80                    8.25

Commission Chargebacks:

        o   Couunissionsare not eamed on policies which are reftmred to the Company and
        o   The Cornpany rvill recovel'arl alllorurt equal to the cormnissionspaid or advancedon
            any policy rvhich, druing its f-rrst policy year was sturenderedfor the policy cash
        o   If the insured dies prior to the first policy arniversary the conunission rvill be charged
            back l00oz'b.
        o   If a policy is issued with an incorrect ase and the correct age rvould have rresulted a
            lorvel conunissiou, a paltial chargebackrvill take place to result ir the conect

I have reacl and sglee *,iilt tlre above:

Signctture:                                                              Date:

Print Full Naue:

                         PO Box 625700 Cincinnati, OH 45262

                            Candidate Notification

Through this document, it is disclosed to you that an investigative consumer report will be
obtained from a consumer reporting agency for the purpose of evaluating you for agent
appointment, employment, promotion, reassignment or retention as an employee or for
eligibility for a license required by law to consider an applicant's financial responsibility.
This report may contain information bearing on your credit worthiness, credit standing,
credit capacity, character, general reputation, personal characteristics, or mode of living from
public record sources or through personal interviews with your neighbors, friends or
associates. You may also have a right to request additional disclosures regarding the nature
and scope of the investigation.
                   PO Box 625 700 Cincinnati, OH 45262

    Authorization to Conduct Background Investigations
  I hereby authorize and request any present or former employer, school, police
  department, financial institution or other persons having personal knowledge about me,
  to furnish bearer with any and all information in their possession regarding me in
  connection with my application for agent appointment, employment or license. I am
  willing that a photocopy of this authorization be accepted with the same authority as the
  original, and I specifically waive any written authorized request. I understand this
  authorization is to be part of the written agent appointment and/or employment
  application which I sign.

  I have been given a stand alone, consumer notification that a report will be requested
  and used for the purpose of evaluating me for employment, agent appointment,
  promotion, reassignment or retention as an employee or for a license required by law to
  consider an applicant ' s financial responsibility.

Print Name

Signature                             ::;:::- Date
                 _ _ _ _ _ _ _ _ _-""~-

Date of Birth
(for identification purposes only)

Social Security Number
(for identification purposes only)

If name changed,
(through marriage of otherwise)
 print fonner name here

I hereby authorize Unity Financial Life Insurance Company to initiate credit enuies and, if necessary , debit
enuies to con-eel elTors or retrieve payments made in etTOr. Unity Financial will not use tlus authorization
for withdrawals or to recover debit balances. I will not hold the banks liable for any elToneous deposits or

Nam(' : Last                                     First                                     M.I.
(Please Print Cl('arly)

               Address                            C ity               State           Zip C odt'

   Agent Numbn (s)

                                   Please Attach a Voided Check Here

Agent Signature                                                            Date

                                 Please return this to Unity Financial by:
                          Fax: 513-247-5040 or Email: agentservices@
                             Want 2417 access to your account
                             information? Sign up for Unity Link

   Unity Link: Unity Financial's Agent Information System

      Full Name:

      a-mail address:

      Signature:                                              Date:

     Return to:
            Agent Services
            Un ity Financial Life Insurance Company
            PO BOX 625700
            Cincinnati Ohio 45262-5700
            Fax: 513-247-5040

W hen your request has been processed , you wil l be notified by ema il with all of the information you need to access
the Unity Li nk Agent System.
                   PO Box 625700 Cincinnati, Ohio 45262

                              ASSIGNMENT OF COMMISSIONS

For valuable consideration, I                              , herein called "ASSIGNOR" hereby assign, transfer
and set over to                                      , hereafter called "ASSIGNEE" all my right, title and
interest in and to all commissions and any other compensation now due and hereafter to become due on all
insurance policies, present and future, heretofore and hereafter issued by Unity Financial Life Insurance
Company (hereinafter called "COMPANY") procured by me or in connection with any of my agency
contracts with the COMPANY and all amendments, additions or supplements hereto and allllew agency
contracts entered into by me with the COMPANY.

ASSIGNEE'S ADDRESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

ASSIGNEE'S TAXPAYER ID NUMBER: _ _ _ _ _ _ _ _ _ _ _ __

The COMPANY is hereby authorized and directed to pay the cOlllmissions and other compensation
f0l1hwith, as they may become due directly to the ASSIGNEE and the receipt of the assignee shall constitute
a full discharge of the COMPANY on accomll of said payments.

The ASSIGNEE acknowledges that they will be responsible for any fmanc ial obligations that result from
business sold for which commissions are assigned pursuant to this agreement.

TIus agreement supersedes any and all assignments executed by the ASSIGNOR relevant to the COMPANY
prior to this date.


ASSIGNOR : _ _ _ _ _ _ _ _ _ _ _ _ _ Date:

ASSIGNEE: _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __

Unity Financial Life Insurance Company, by its Officer,

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __
F~m          W-9
(Rev. October 2(07)
                                                                Request for Taxpayer                                                          Give form to t he
                                                                                                                                              reque ster. Do not
Depattmen! 01 the Trea:wt)'
                                                      Identification Number and Certification                                                 send to t he lAS.
InIfWnaI RevenutI $ervIo8
             Name (as shown       00    your income

             Business name. if different from above
&~           Check appropriate box:        D
                                          Indivklua1lSole proprietor   D     Corporation    D    Partnership
                                                                                                                                           D    Exempt
;, .-        D  limited liability company. Enter the lax classifica~on (D:disregarded entity. C:oorporation, P:partnership) ~ -- -----
< •

             D                              •
             Address (number, street, and apt. or suite no.)                                                                   name and address (opliooaO
~ 0
       0     C~y,   state, and ZIP code

      $                                         ,{o~;~'

                                                                  r (TI N)

Enter your TIN In the appropriate box. The TIN provided must match the name given on Line 1 to avoid                          I Social secu~ num~er
backup withhold ing . For individuals, this is your social security number (SSN). However, !Of a resident
alien, sale 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 a TIN on page 3.                                        0'
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose                                                         number
number to enter.

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 fa ilure 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. citizen or other U.S. person (defined below).
Certifi cation 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 fa iled to report all interest and dividends on your tax return. For rea l 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 4.
Sig n

General Instructions
                    Sig nature of
                    u.s. person     ~

Section references are to the Intemal Revenue Code unless
                                                                                                    -'           Cate ~

                                                                                          Definition of a U,S. person. For federal tax purposes, you are
                                                                                          considered a U.S. person if you are:
                                                                                          • An individual who is a U.S. citizen or U.S. resident alien,
otherwise noted.
                                                                                          • A partnership, corporat ion, company, or association created or
Purpose of Form                                                                           organized in the United States or under the laws of the United
A person who is required to file an information retum with the                            States,
IRS must obtain your correct taxpayer identification number (TIN)                         • An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate                                   • A domestic trust (as defined in Regulat ions section
transactions, mortgage interest you paid, acquisition or                                  301 .7701-7).
abandonment of secured property, cancellation of debt , or
                                                                                          Special rules for partnerships. Partnerships that conduct a
contribut ions you made to an IRA.
                                                                                          trade or business in the United States are generally required to
   Use Form W-g only if you are a U.S. person (including a                                pay a withholding tax on any foreign partners' share of income
resident alien), to provide your correct TIN to the person                                from such business. Further, in certain cases where a Form W-g
requesting it (the requester) and, when applicable, to:                                   has not been received, a partnership is required to presume that
  1. Certify that the TIN you are giving is correct (or you are                           a partner is a foreign person, and pay the wit hholding tax.
wait ing for a number to be issued),                                                      Therefore, if you are a U.S. person that is a partner in a
                                                                                          partnership conducting a trade or business in t he United States,
   2. Certify that you are not subject to backup withholding, or                          provide Form W-9 to the partnership to establish your U.S.
   3. Claim exemption from backup withholding if you are a U.S.                           status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying t hat as a                           income.
U.S. person, your allocable share of any partnership income from                             The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to t he withholding tax on                        purposes of establishing its U.S. status and avoiding withholding
foreign partners' share of effectively connected income.                                  on its allocable share of net income from the partnership
 Note. If a requester gives you a form other than Form W-g to                             conducting a trade or business in t he United States is in t he
request your TIN, you must use t he requester's form if it is                             following cases:
substantially similar to this Form W-g.
                                                                                          • The U.S. owner of a disregarded entity and not the entity,

                                                                              Cat. No. 10231X                                              FOfm   W-9    (REW. 10-2007)
Form W-9 (Rev. 10-2(07)

• The U.S. grantor or other owner of a grantor t rust and not the           4. The IRS tells you that you are subject to backup
trust, and                                                               withholding because you did not report all your interest and
• The U.S. trust (other than a grantor trust) and not the                dividends on your tax return (for reportable interest and
beneficiaries of the trust.                                              dividends only), or
Foreig n person. If you are a foreign person, do not use Form              5. You do not certify to the requester that you are not subject
W-9. Instead, use t he appropriate Form W-8 (see Publication             to backup withholding under 4 above (for reportable interest and
515, Withholding of Tax on Nonresident Aliens and Foreign                dividend accounts opened after 1983 only).
Entit ies).                                                                Certain payees and payments are exempt from backup
                                                                         withholding. See the instructions below and the separate
Nonresident alien w ho becomes a resident alien. Generally,
                                                                         Instruct ions for t he Requester of Form W-9.
only a nonresident alien individual may use t he terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.          Also see Special rules for partnerships on page 1.
However, most tax treaties contain a provision known as a                Penalties
~saving clause." Except ions specifi ed in t he saving clause may
permit an exemption from tax to continue for certain types of            Failure to f urnish TIN. If you fa il to furnish your correct TIN to a
income even after the payee has otherwise become a U.S.                  requester, you are subject to a penalty of $50 for each such
resident alien for tax purposes.                                         fa ilure unless your fa ilure is due to reasonable cause and not to
   If you are a U.S. resident alien who is rel ying on an except ion     willful neglect.
contained in the saving clause of a tax treaty to claim an               Civil penalty fo r false informatio n w ith respect to
exemption from U.S. tax on certain types of income, you must             w ithholding. If you make a false statement wit h no reasonable
attach a statement to Form W-9 t hat specifies the follow ing five       basis that results in no backup withholding, you are subject to a
items:                                                                   $500 penalty.
   1. The t reaty country. Generally, this must be the same treaty       Criminal penalty fo r f alsifyi ng info rmation. Willfully falsifying
under which you claimed exemption from tax as a nonresident              certifications or affirmations may subject you to criminal
alien.                                                                   penalties including fi nes and/ or imprisonment.
   2. The treaty article addressing the income.                          Misuse of TINs. If the requester discloses or uses TINs in
   3. The article number (or location) in t he tax treaty that           violation of federal law, the requester may be subject to civil and
contains the saving clause and its exceptions.                           criminal penalt ies.
   4. The type and amount of income that qualifies for the
exemption from tax.                                                      Specific Instructions
   5. Sufficient facts to just ify the exemption from tax under t he     Name
terms of the treaty article.
   Example. Article 20 of the U.S.-China income tax treaty allows        If you are an individual , you must generally enter the name
                                                                         shown on your income tax return. However, if you have changed
an exemption from tax for scholarship income received by a
                                                                         your last name, for instance, due to marriage without informing
Chinese student temporaril y present in t he United States. Under
                                                                         the Social Security Administ rat ion of the name change, enter
U.S. law, t his student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5               your first name, the last name shown on your social security
                                                                         card , and your new last name.
calendar years. However, paragraph 2 of the first Protocol to t he
U.S.-China t reaty (dated April 30, 1984) allows the provisions of          If the account is in joint names, list first, and then circle, the
Article 20 to cont inue to apply even after t he Chinese student         name of the person or entity whose number you entered in Part I
becomes a resident alien of t he United States. A Chinese                of the form.
student who qualifies for this exception (under paragraph 2 of           Sole pro priet or. Enter your individual name as shown on your
the first protocol) and is relying on this exception to claim an         income tax ret urn on the "Name" line. You may enter your
exemption from tax on his or her scholarship or fellowship               business, t rade, or "doing business as (DBA)" name on the
income would attach to Form W-9 a statement that includes the            ~B usiness name" line.
information described above to support that exemption .
                                                                         Limited liability company (LLC). Check the "Umited liability
   If you are a nonresident alien or a fore ign ent ity not subject to   company" box only and enter the appropriate code fo r the tax
backup withholding , give t he requester the appropriate                 classification (~D " for disregarded entity, "C" for corporation, "P"
completed Form W-8.                                                      for partnership) in the space provided.
What is backup w ithholding? Persons making certain payments                For a single-member LLC (including a fo reign LLC wit h a
to you must under certain condit ions withhold and pay to the            domest ic owner) that is disregarded as an entity separate from
IRS 28% of such payments. This is called "backup withholding ."          its owner under Regulations section 301.7701-3, enter the
Payments that may be subject to backup withholding include               owner's name on t he ~ Name " line. Enter the LLC's name on t he
interest, tax-exempt interest, dividends, broker and barter              ~B usiness name" line.
exchange t ransactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate                   For an LLC classified as a partnership or a corporation, enter
transactions are not subject to backup withholding.                      the LLC's name on the "Name" line and any business, t rade, or
                                                                         DBA name on the "Business name" line.
   You will not be subject to backup wit hholding on payments
you recei ve if you give the requester your correct TIN, make the        Ot her ent ities. Enter your business name as shown on required
proper certificat ions, and report all your taxable interest and         federal tax documents on the "Name" line. This name should
dividends on your tax return.                                            match the name shown on the charter or other legal document
                                                                         creating t he entity. You may enter any business, trade, or DBA
Payment s you receive w ill be subject to backup                         name on the "Business name" line.
w ithho lding if:                                                        Not e. You are requested to check the appropriate box fo r your
   1. You do not fu rnish your TIN to the requester,                     status (individual/sole proprietor, corporation, etc.).
   2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
                                                                         Exempt Payee
                                                                         If you are exempt from backup withholding, enter your name as
   3. The IRS tells the requester that you furnished an incorrect
                                                                         described above and check the appropriate box for your status,
                                                                         then check the "Exempt payee" box in the line followi ng t he
                                                                         business name, sign and date the form.
Fonn W-9 (Rev. 10-2007)                                                                                                                       Page   3
Generally, individuals ~ncluding sole proprietors) are not exempt                Part I. Taxpayer Identification
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.                Number (TIN)
Note. If you are exempt from backup withholding, you should                      Enter your TIN in the appropriate box. If you are a resident
still complete this form to avoid possible erroneous backup                      alien and you do not have and are not eligible to get an SSN,
wit hholding.                                                                    your TIN is your IRS individual taxpayer identification number
   The following payees are exempt from backup withholding:                      (ITIN). Enter it in t he social security number box. If you do not
                                                                                 have an ITIN, see How to get a TIN below.
  1. An organizat ion exempt from tax under section 501 (a), any
                                                                                    If you are a sole proprietor and you have an EIN, you may
IRA, or a custodial account under section 403(b)(7) if the account
                                                                                 enter either your SSN or EIN. However, the IRS prefers that you
satisfies the requirements of section 401 (1)(2),
                                                                                 use your SSN .
   2. The United States or any of its agencies or                                   If you are a single-member LLC that is disregarded as an
instrumentalities,                                                               entity separate from its owner (see Umited liability company
  3. A state, the District of Columbia, a possession of t he United              (LLC) on page 2), enter t he owner' s SSN (or EIN, if the owner
States, or any of t heir political subdivisions or instrumentalities,            has one). Do not enter the disregarded entity's EIN. If the LLC is
  4. A foreign government or any of its political subdivisions,                  classified as a corporat ion or partnership, enter the entity's EIN.
agencies, or inst rumentalities, or                                              Note. See the chart on page 4 for further clarification of name
                                                                                 and TIN combinations.
   5. An international organization or any of its agencies or
instrumentalities.                                                               How to get a TIN. If you do not have a TIN, apply for one
                                                                                 immediately. To apply for an SSN, get Form SS-5, Application
   Other payees that may be exempt from backup withholding                       for a Social Security Card, from your local Social Security
include:                                                                         Administration office or get t his form online at You
   6. A corporation,                                                             may also get t his form by calling 1-800-772-1213. Use Form
  7. A foreign cent ral bank of issue,                                           W-7, Application for IRS Individual Taxpayer Identification
  8. A dealer in securities or commodities required to register in               Number, to apply for an ITIN, or Form SS-4, Application for
the United States, the District of Columbia, or a possession of                  Employer Identification Number, to apply for an EIN . You can
the United States,                                                               apply for an EIN online by accessing the IRS website at
                                                                        and clicking on Employer Identification
   g. A futures commission merchant registered with the                          Number (EIN) under Starting a Business. You can get Forms W-7
Commodity Futures Trading Commission,                                            and SS-4 from the IRS by visiting or by calling
  10. A real estate invest ment trust,                                           1-800-TAX-FORM (1-800-829-3676).
   11 . An entity registered at all times during the tax year under                 If you are asked to complete Form W-9 but do not have a TIN,
the Invest ment Company Act of 1940,                                             write "Applied For n in the space for the TI N, sign and date the
                                                                                 form, and give it to t he requester. For interest and dividend
  12. A common trust fund operated by a bank under section                       payments, and certain payments made with respect to readily
584(a),                                                                          tradable inst ruments, generally you will have 60 days to get a
  13. A financial institution,                                                   TIN and give it to the req uester before you are subject to backup
  14. A middleman known in t he investment community as a                        withholding on payments. The 6O-day rule does not apply to
nominee or custodian, or                                                         other types of payments. You will be subject to backup
                                                                                 withholding on all such payments unt il you provide your TIN to
  15. A trust exempt from tax under section 664 or described in                  the req uester.
section 4947 .
                                                                                 Note. Entering "Applied For" means that you have already
  The chart below shows types of payments that may be                            applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding. The chart applies to the                         Caution: A disregarded domestic entity that has a foreign owner
exempt payees listed above, 1 through 15.                                        must use the appropriate Form W-B.
IF the payment is for ...                THEN the payment is exempt              Part II. Certification
                                         for ...
                                                                                 To establish to the withholding agent that you are a U.S. person,
Interest and dividend payments           All exempt payees except                or resident alien, sign Form W-9. You may be requested to sign
                                         for 9                                   by the withholding agent even if items 1, 4, and 5 below indicate
Broker transactions                      Exempt payees 1 through 13.             otherwise.
                                         Also, a person registered under            For a joint account, only the person whose TIN is shown in
                                         the Investment Advisers Act of          Part I should sign (when req uired). Exempt payees, see Exempt
                                         1940 who regular1y acts as a            Payee on page 2.
                                         broker                                  Signature requirements. Complete the certificat ion as indicated
Barter exchange transactions             Exempt payees 1 through 5               in 1 through 5 below.
and patrooage dividends                                                            1. Interest, dividend, and barter exchange accounts
                                                                                 opened before 1984 and broker accounts considered active
Payments over $600 required              Generally, e~empt payees                during 1983. You must give your correct TIN, but you do not
to be reported and direct                1 through 7                             have to sign the certification .
sales over $5,000'
                                                                                    2. Interest, dividend, broker, and barter exchange
                                                                                 accounts opened after 1983 and broker accounts considered
, Fonn 1099-MISC, Miscellaneous Income, and its instructionS.                    inactive during 1983. You must sign the certification or backup
 However, the following payments made to a corporation (Including 9ross
 proceeds paid to an attOfney under section 6045(1), even if the attOfney is a
                                                                                 withholding will apply. If you are subject to backup withholding
 COfpoo:ltion) and reportable on FOfm 1099-MISC are not exempt from              and you are merely providing your correct TIN to t he requester,
 backup withholding: medical and health care payments , attorneys· fees, and     you must cross out item 2 in the certificat ion before signing the
 payments fOf seNices paid by a fedefal execu~ve agency.                         form.
Form W-9 (Rev. 10-2(07)

  3. Real estate transactions. You must sign t he certification.                                  Secure Your Tax Records from Identity Theft
You may cross out item 2 of the certification.
                                                                                                  Identity theft occurs when someone uses your personal
  4. Other payments. You must give your correct TIN, but you                                      information such as your name, social security number (SSNj, or
do not have to sign the certification unless you have been                                        ot her identifying information, without your permission, to commit
notified that you have previously given an incorrect TIN. "Other                                  fraud or other crimes. An identity thief may use your SSN to get
payments" include payments made in the course of the                                              a job or may file a tax return using your SSN to receive a refund.
requester's trade or business for rents, royalties, goods (ot her
than bills for merchandise), medical and health care services                                        To reduce your risk:
~ncluding payments to corporations), payments to a                                                • Protect your SSN,
nonemployee for services, payments to certain fishing boat crew                                   • Ensure your employer is protecting your SSN, and
members and fishermen, and gross proceeds paid to attorneys
                                                                                                  • Be careful when choosing a tax preparer.
~ncluding payments to corporations).
                                                                                                     Call t he IRS at 1-800-829-1040 if you t hink YOUf identity has
  5. Mortgage int erest paid by you, acquisition or                                               been used inappropriately fo r tax purposes.
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,                                         Victims of identity t heft who are experiencing economic harm
Coverdell ESA, Archer MSA or HSA contributions or                                                 or a system problem, or are seeking help in resolving tax
distributions, and pension distributions. You must give your                                      problems that have not been resolved through normal channels,
correct TIN, but you do not have to sign t he certification.                                      may be eligible for Taxpayer Advocate Service (TAS) assistance.
                                                                                                  You can reach TAS by calling the TAS toll-free case intake line
                                                                                                  at 1-877-777-4778 or TIYfTDD 1-800-829-4059.
What Name and Number To Give the Requester
                                                                                                  Protect yourself from suspicious emails or phishing
          For thi s type of account:                     Give name and SSN of:                    schemes. Phishing is the creation and use of email and
                                                                                                  websites designed to mimic legitimate business emails and
    1. Individual                                  The individual
                                                                                                  websites. The most common act is sending an email to a user
    2. Two or more individuals fjoint              The actual owner of the account or,
       account)                                    if combined funds, the first
                                                                                                  falsely claiming to be an established legitimate enterprise in an
                                                   individual on the account '                    attempt to scam the user into surrendering private informat ion
    3. Custodian account of a minor                The minor'                                     that will be used for identity theft.
       (Uniform Gift to Minors Act)                                                                  The IRS does not initiate contacts with taxpayers via emails.
    4. a. The usual revocable savings              The grantor- trustee '                         Also, the IRS does not request personal detailed information
       trust (grantor is also trustee)                                                            through email or ask taxpayers for the PIN numbers, passwords,
       b. So-called trust account that is          The actual owner '                             or similar secret access informat ion for their credit card, bank, or
       not a legal or valid trust under                                                           ot her financial accounts.
       state law
    5. Sole proprietorship or distegarded          The owner '                                       If you receive an unsolicited email claiming to be from the IRS,
       entity owned by an individual                                                              forward this message to You may also report
                                                                                                  misuse of the IRS name, logo, or ot her IRS personal property to
          For thi s type of account:                      Give n ame and EIN o f:
                                                                                                  the Treasury Inspector General for Tax Administration at
    6. Disregarded entily not owned by an                                                         1-800-366-4484. You can forward suspicious emails to the
       individual                                                                                 Federal Trade Commission at: spam@uce.govorcontact them at
    7. A valid trus~ estate, or pension trusl      legal entity                                   www.consumer.govlidtheft or 1-877 -IDTHEFT(438-4338).
    8. Corporate or llC electing                   The corporation
       cooporate status on Form 8832                                                                Visit the IRS website at www.irs.govto learn more about
 9. Association, Club, religious,                  The organization                               identity theft and how to reduce your risk.
    charitable, educational, or other
    tax-exempt organization
10. Partnership or multi-member ll.C               The partnef'Ship
11. A broker or registered nominee                 The broker or nominee
12. Account with the Department o f                The public entity
    Agriculture in the name of a public
    entity (such as a state or local
    government, school district, or
    prison) that receives agricultural
    program payments
 Ust rnt and circle the """'" <A !he pet'$OIl whose numt:>er )IOU furnish. H only one person
 on a joint a>::c(lU"I! has an SSN,!hat person·s numt:>er rrust to. fumlshed.
'CIrcle !he minor's name...-.::l furnish !he minor's SSN.
 Yoo rrust $how your IndIYklual name...-.::l)lOU"""'" abo ..,1 your bushess Of "DBA-
 """'" on !he second name I"". You"....." lI$/I e/!het your SSN Of EIN (If)lOU have one),
 but !he IRS ~)IOU 10 use your SSN .
• Ust !hi and cO-cIe the name of !he !ruSt, <l$l8le, Of pen$IOn trost. (Do I"W)! fumish the TIN
  01 the personal ~ Of trostN unIes$ !he legal ..,1IIy Itself Is I"W)! designated In
  the ac;:c;oo.m t1!1e.) Also see $p.cItII nJIes for ptJIf1Ief$I1IpS on poJge 1.
Note. If no name is circled when more t han one name is listed,
the number will be considered to be that of t he first name listed .

Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage inlerest you paid, the acquisition or abandonment of secured propIIfty, cancellation o f debt, or
contributions you made to an IRA, or AIcher MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax retum.
The IRS may also provide this information to the Department of Justice for civil and criminallitigalion, and to cities, states. the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to fedefal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
  You must provide your TIN whether or not \>OU are required to file a tax retum. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.