Instructions On How to Open an IRA With GoldStar Trust Company As Custodian And

Invest In A HIS Fund Note Through The IRA

1. Review the Current Prospectus of HIS Fund.

2. Complete the GoldStar Trust Company paperwork to open the IRA.

3. Complete the Release and Authorization for GoldStar Trust Company, as your custodian, to purchase HIS Fund Notes for your IRA, and to share information with HIS Fund.

4. Complete a HIS Fund Individual Note Purchase Application for a Self-Directed IRA.

5. Mail the completed documentation to HIS Fund at the following address along with your check payable to GoldStar Trust. HIS Fund will then forward to GoldStar Trust Company:

HIS Fund, Inc. c/o IRA Processing 3 Kacey Court, Suite 101 Mechanicsburg, PA 17055

6. HIS Fund will pay your first year maintenance fee. You are responsible for the maintenance fee on the anniversary date of year two and thereafter. GoldStar will bill you directly for the maintenance fee annually upon the anniversary date of your IRA.

If you have any questions, you may call us at 717-796-9784 or 866-219-0820. HIS Fund is a 501(c)(3) nonprofit corporation and is not affiliated with GoldStar Trust Company in any way. Any information provided about GoldStar Trust Company is solely the responsibility of GoldStar Trust Company. HIS Fund disclaims any responsibility for compliance with IRA regulations, which is solely the responsibility of the IRA custodian and account holder. THE NOTES OF HIS FUND WILL BE OFFERED AND SOLD ONLY TO PERSONS WHO ARE, PRIOR TO OR AT THE TIME OF RECEIVING A PURCHASE APPLICATION, MEMBERS OF, CONTRIBUTORS TO OR PARTICIPANTS IN THE GENERAL COUNCIL OF THE ASSEMBLIES OF GOD, THE PENNSYLVANIA-DELAWARE DISTRICT COUNCIL OF THE ASSEMBLIES OF GOD, OR IN ANY PROGRAM, ACTIVITY OR ORGANIZATION WHICH CONSTITUTES A PART OF THE GENERAL COUNCIL, OR THE DISTRICT COUNCIL OR IN OTHER CHURCH ORGANZIATIONS THAT HAVE A PROGRAMMATIC RELATIONSHIP WITH THE GENERAL COUNCIL OR THE DISTRICT COUNCIL, AND SELF-DIRECTED INDIVIDUAL RETIREMENT ACCOUNTS OF SUCH PERSONS. THE NOTES OF HIS FUND ARE NOT SAVINGS OR DEPOSIT ACCOUNTS OR OTHER OBLIGATIONS OF A BANK AND ARE NOT INSURED BY THE FEDERAL DEPOSIT INSURANCE CORPORATION, ANY STATE BANK INSURANCE FUND, THE SECURITIES INVESTOR PROTECTION CORPORATION OR ANY OTHER GOVERNMENTAL AGENCY. THE NOTES ARE OBLIGATIONS OF HERITAGE INVESTMENT SERVICES FUND, INC. AND ARE NOT OBLIGATIONS OF NOR GUARANTEED BY, THE PENNSYLVANIA-DELAWARE DISTRICT COUNCIL OF THE ASSEMBLIES OF GOD, THE ASSEMBLIES OF GOD, OR BY ANY CHURCH, CONFERENCE, INSTITUTION OR AGENCY AFFLIATED WITH THE ASSEMBLIES OF GOD OTHER THAN HERITAGE INVESTMENT SERVICES FUND, INC. This information is neither an offer to sell nor a solicitation of an offer to buy these securities. The offer is made only by the prospectus. 719982.2

Appendix B-3 – Page 1 2020-2021

SELF-DIRECTED IRA NOTE PURCHASE APPLICATION

Please complete and sign this application and return it, along with your check, to the above address. A separate purchase application must be completed and submitted

for each Note you desire to purchase. Heritage Investment Services Fund, Inc. (HIS Fund), in its discretion, may limit the number of Notes an investor may hold (any

limitation will be applied separately to Notes purchased for an IRA). Checks from IRA owners should be made payable to your IRA custodian, who will be responsible

for delivering the amount of the purchase price to HIS Fund. By signing this Application, the IRA account owner is instructing the custodian or trustee of the IRA to

purchase the Note indicated below.

TYPE OF IRA

(Choose one):

Roth IRA

Traditional IRA

Simple IRA

SEP IRA

Self-Directed IRA Account Owner Custodian/Trustee Information

First Name

MI Last Name IRA Custodian

GoldStar Trust Company, P.O. Box 719, Canyon, TX 79015-0719

Social Security Number

Date of Birth (mm/dd/yyyy) If your IRA custodian or trustee is not as indicated above, please cross out the name typed above and provide correct information below:

Mailing Address: Custodian Name

City State Zip Street

Telephone No. City State Zip

Email Telephone No.

This is my new address; please update your records accordingly.

Email:

☐ Electronic Delivery Agreement: (Check the box to go paperless). In lieu of receiving a mailed copy of HIS Fund’s Prospectus, Financial Statements

and all other HIS Fund documents (i.e. periodic investment statements, deposit receipts and confirmation of purchase issuance letters), I request HIS

Fund to send me, via email, notification that the Prospectus, Financial Statements and other HIS Fund documents are available for review through or on HIS Fund’s website. I understand I may revoke this request at any time or change the delivery address by contacting HIS Fund.

Amount of Purchase: $ ($500 minimum) (DO NOT SEND CASH)

Checks should be made payable to your Custodian/Trustee

Investment Instruction (Enter the dollar amount for each type of Note in which you want to invest):

Demand Note

(not available in South Carolina)

$ 6 Month Note $

1 Year Note $ 2 ½ Year Note $

4 Year Note $ 5 Year Note $

5 Year Jumbo Note (minimum of $100,000)

$

3 KACEY COURT, SUITE 101

MECHANICSBURG, PA 17055 E-MAIL: invest@hisfund.com

TOLL FREE: (866) 219-0820

PHONE: (717) 796-9784

FAX: (717)795-9568

www.hisfund.com

Appendix B-3 – Page 2 2020-2021

INVESTOR HAS NO RIGHT OF WITHDRAWAL PRIOR TO MATURITY. If HIS Fund, in its discretion, permits early withdrawal, an

interest penalty, processing fee and other withdrawal conditions may apply. Restrictions on transfer apply. See “DESCRIPTION OF

SECURITIES – Restrictions on Withdrawal and Transfer; Penalty, Fee and Other Conditions on Voluntary Redemption” in the Prospectus.

Interest Options

Compound Interest (redeposit quarterly)

OR Pay Interest:

Monthly Quarterly Semi-Annually Annually (not available with 2 ½ Year Note)

Use existing ACH instructions on file

Establish new ACH by completing a Direct Deposit Form

The undersigned hereby applies to purchase a Note in accordance with this Application and the provisions of the current Prospectus, receipt of which is hereby acknowledged. The undersigned represents that the undersigned is a member of, contributor to or participant in the General Council of the Assemblies of God, the Pennsylvania-Delaware District Council of the Assemblies of God, or in a program, activity, or organization which constitutes a part of the General Council or the District Council, or in a church organization that has a programmatic relationship with the General Council or the District Council.

___________________________________________________

Self-Directed IRA Account Owner Signature

___________________________________________________

Date

How did you hear about us? Check any that apply – District Council Conference Pastor From a friend Other:

Acceptance of this Application by HIS Fund will be evidenced by a written confirmation. HIS Fund reserves the right to reject any application

for any reason in its discretion.

IF YOU HAVE ACCEPTED AN OFFER TO PURCHASE THESE SECURITIES DESCRIBED IN A PROSPECTUS WHICH CONTAINS A

NOTICE EXPLAINING YOUR RIGHT TO WITHDRAW YOUR ACCEPTANCE PURSUANT TO SECTION 207(m)(1) OF THE PENNSYLVANIA SECURITIES ACT OF 1972 (70 P.S. §1-207(m)), YOU MAY ELECT, WITHIN TWO BUSINESS DAYS AFTER THE FIRST TIME YOU HAVE RECEIVED THIS NOTICE AND A PROSPECTUS (WHICH IS NOT MATERIALLY DIFFERENT FROM THE FINAL PROSPECTUS), TO WITHDRAW FROM YOUR PURCHASE AND RECEIVE A FULL REFUND OF ALL MONIES PAID BY YOU. YOUR WITHDRAWAL WILL BE WITHOUT ANY FURTHER LIABILITY TO ANY PERSON. TO ACCOMPLISH THIS WITHDRAWAL, YOU NEED ONLY SEND A WRITTEN NOTICE (INCLUDING A NOTICE BY FACSIMILE OR ELECTRONIC MAIL) TO THE ISSUER (OR UNDERWRITER IF ONE IS LISTED ON THE FRONT PAGE OF THE PROSPECTUS) INDICATING YOUR INTENTION TO WITHDRAW.

GOLDSTAR TRUST COMPANY

RELEASE AND AUTHORIZATION

ACCOUNT HOLDER INFORMATION FOR INVESTMENT IN NOTES ISSUED BY HERITAGE

INVESTMENT SERVICES FUND, INC. (HIS FUND) THROUGH SELF-DIRECTED IRA

Full Legal Name:

Social Security Number:

Address:

City: State: Zip:

Home Phone: Business Phone:

Church Name:

ACCOUNT INFORMATION:

IRA Type Traditional Roth

RELEASE OF LIABILITY FOR INVESTMENT

I understand and agree that in directing GOLDSTAR TRUST COMPANY, as my custodian, to complete a purchase

of Notes issued by Heritage Investment Services Fund, Inc. (HIS Fund) for my account, GoldStar Trust Company

assumes or incurs no liability as to the asset purchased, the appropriateness or worthiness of the investment, or

otherwise. GoldStar Trust Company’s only responsibility is to determine if what is purchased agrees with my investment direction. I have made my own investigation of the risks involved in making the investment in HIS Fund Notes and I

understand those risks. I do hereby indemnify and hold forever harmless GoldStar Trust Company, its officers,

employees, directors, successors, and assigns of and from any claim which may arise or result from purchase of the investments I authorize.

This form contains important disclosures about your duties and responsibilities with regard to holding an alternative investment or nonstandard asset within your self-directed IRA. Such investments may involve a high-degree of risk and

GoldStar Trust Company (“GoldStar”) will make no investigation as to the viability or safety of the investment(s) you

select. GoldStar does not offer investment advice and does not buy or sell investment products. GoldStar is disqualified

by the Internal Revenue Code from trading within an IRA for which it is the custodian. GoldStar is compensated through administrative fees and cash management fees.

AUTHORIZATION AND ACKNOWLEDGMENT

I direct GoldStar Trust Company (“GoldStar”) to make the investment shown on this form. I acknowledge:

Self-Directed IRA investments are not FDIC insured, are not guaranteed by GoldStar and may involve a high-degree of risk including possible loss of principal.

I am solely responsible for directing all investment transactions, including reinvestment of earnings and sale

proceeds.

I am solely responsible for determining the investments I direct are allowable under applicable law and

regulations.

GoldStar has no discretion or responsibility to direct any investment for my self-directed IRA.

GoldStar will not exercise any discretion, assume any fiduciary responsibility, perform a due diligence review, or undertake any investigation as to the prudence, viability, merits or suitability of the Investment.

GoldStar has no responsibility for investment or tax advice and I am responsible for any information on

which I rely.

Cash in my self-directed IRA will be invested as explained in Investment of Amounts in the IRA section of

the Account Agreement, as amended.

GoldStar is not a “fiduciary”, or a person entitles to exercise any discretionary authority with respect to the

Investment, as those terms and concepts are defined in the Internal Revenue Code, ERISA, or other applicable federal, state, or local laws.

I agree to indemnify and hold harmless GoldStar, its officers, directors and employees from and against all

losses, expenses, damages and costs including reasonable attorney’s fees which may occur as a result of the

execution of this investment direction.

RELEASE OF IRA ACCOUNT INFORMATION

GoldStar Trust Company as my custodian is hereby authorized to release account balance information to HIS Fund and its

representatives. I understand that this allows HIS Fund, which will or has sold me the HIS Fund Note(s) in my account,

and its representatives to know the status of my account. Upon my signing this release, my custodian may release my account information to HIS Fund and its representative on its or their request. I hereby release and agree to hold harmless GoldStar Trust Company from all liability arising out of the release of all account information.

Signature Date

719969.4

Page 1 of 156100 (Rev. 10/2014) ©2014 Ascensus, Inc.

PART 1. IRA OWNER

Name (First/MI/Last) _________________________________________

Street Address (Physical Required)

___________________________________________________________

City/State/ZIP________________________________________________

Mailing Address (If different from Street Address)

___________________________________________________________

City/State/ZIP________________________________________________

Social Security Number ________________________________________

Date of Birth ________________________________________________

Home Phone ________________________________________________

Daytime Phone ______________________________________________

Email Address _______________________________________________

Preferred Method of Contact ___________________________________

PART 2. ROTH IRA CUSTODIAN

Name ______________________________________________________

Address Line 1 _______________________________________________

Address Line 2 _______________________________________________

City/State/ZIP________________________________________________

Phone _____________________________________________________

GoldStar Account Number

___________________________________________________________(To be completed by GTC)

PART 4. CONTRIBUTION INFORMATION

Contribution Amount ____________________________ Contribution Date ________________

CONTRIBUTION TYPE (Select one)

1. Regular (Includes catch‐up contributions)

Contribution for Tax Year _________

2. Rollover (Distribution from a Roth IRA or eligible employer‐sponsored retirement plan that is being deposited into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a rollover.

3. Transfer (Direct movement of assets from a Roth IRA into this Roth IRA)

4. Recharacterization (A nontaxable movement of a Traditional IRA contribution into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a recharacterization.

5. Conversion (A taxable movement from a Traditional IRA or SIMPLE IRA into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a conversion.

ROTH INDIVIDUAL RETIREMENT ACCOUNTAPPLICATIONSimplifier®

ROTH

IRA

GoldStar Trust CompanyP.O. Box 719 (Mailing)1401 4th Avenue (Street)Canyon, TX 79015(800) 486-6888

PART 3. CUSTOMER IDENTIFICATION PROGRAM INFORMATION (CIP)

USA PATRIOT Act NoticeIn order to comply with the USA PATRIOT Act, we must be able to identify our customer. All new accounts must provide us with either the driver’slicense information; a photocopy of an unexpired, photo‐bearing, government‐issued identification, such as a passport, military, veteran or similar ID;or a notarized document.

Driver’s License # _____________________________________________ State Issued _________________________________________________

Issuance Date _______________________________________________ Expiration Date ______________________________________________

If you do not have a valid state‐issued driver’s license, you must provide a legible photocopy of a valid government‐issued photo ID or a notarizeddocument.

Page 2 of 156100 (Rev. 10/2014) ©2014 Ascensus, Inc.

Check here if additional beneficiaries are listed on an attached addendum. Total number of addendums attached to this Roth IRA ______________

PART 6. SPOUSAL CONSENT

Spousal consent should be considered if either the trust or the residence ofthe Roth IRA owner is located in a community or marital property state.

CURRENT MARITAL STATUSI Am Not Married – I understand that if I become married in thefuture, I should review the requirements for spousal consent.I Am Married – I understand that if I choose to designate a primarybeneficiary other than or in addition to my spouse, my spouse shouldsign below.

CONSENT OF SPOUSEI am the spouse of the above‐named Roth IRA owner. I acknowledge that Ihave received a fair and reasonable disclosure of my spouse’s property andfinancial obligations. Because of the important tax consequences of givingup my interest in this Roth IRA, I have been advised to see a tax professional.I hereby give the Roth IRA owner my interest in the assets or propertydeposited in this Roth IRA and consent to the beneficiary designationindicated above. I assume full responsibility for any adverse consequencesthat may result. No tax or legal advice was given to me by the Custodian.

X____________________________________________ _____________________Signature of Spouse Date (mm/dd/yyyy)

PART 7. SIGNATURES

Important: Please read before signing.I understand the eligibility requirements for the type of Roth IRA deposit I ammaking, and I state that I do qualify to make the deposit. I have received a copyof the Roth IRA Application, 5305‐RA Custodial Account Agreement, theFinancial Disclosure, and the Disclosure Statement. I understand that the termsand conditions that apply to this Roth IRA are contained in this Application andthe Custodial Account Agreement. I agree to be bound by those terms andconditions. Within seven days from the date I open this Roth IRA I may revokeit without penalty by mailing or delivering a written notice to the custodian.I assume complete responsibility for

• determining that I am eligible for a Roth IRA each year I make acontribution,

• ensuring that all contributions I make are within the limits set forthby the tax laws, and

• the tax consequences of any contributions (including rollovercontributions and conversions) and distributions.

I expressly certify that I take complete responsibility for the type ofinvestment instrument(s) I choose to fund my IRA, and that the Custodianis released of any liability regarding the performance of any investmentchoice I make.

X____________________________________________ _____________________Signature of Roth IRA Owner Date (mm/dd/yyyy)

X____________________________________________ _____________________Signature of Custodian Date (mm/dd/yyyy)

PART 5. BENEFICIARY DESIGNATION

I designate that upon my death, the assets in this account be paid to the beneficiaries named below. The interest of any beneficiary that predeceasesme terminates completely, and the percentage share of any remaining beneficiaries will be increased on a pro rata basis. If no beneficiaries arenamed, my estate will be my beneficiary.

I elect not to designate beneficiaries at this time and understand that I may designate beneficiaries at a later date.

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address_____________________________________________________

City/State/ZIP________________________________________________

Date of Birth _________________ Relationship ____________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

CONTINGENT BENEFICIARIES (The total percentage designated must equal 100%.) (The balance in the account will be payable to these beneficiariesif all primary beneficiaries have predeceased the Roth IRA owner.)

PRIMARY BENEFICIARIES (The total percentage designated must equal 100%.)

This is page 2 of the Roth IRA Application for__________________________________________, Account Number _____________________________

Page 7 of 15

The depositor named on the application is establishing a Roth individualretirement account under section 408A to provide for his or herretirement and for the support of his or her beneficiaries after death.

The custodian named on the application has given the depositor thedisclosure statement required by Regulations section 1.408‐6.

The depositor has assigned the custodial account the sum indicated on theapplication.

The depositor and the custodian make the following agreement:

ARTICLE IExcept in the case of a rollover contribution described in section 408A(e),a recharacterized contribution described in section 408A(d)(6), or an IRAconversion contribution, the custodian will accept only cash contributionsup to $3,000 per year for tax years 2002 through 2004. That contributionlimit is increased to $4,000 for tax years 2005 through 2007 and $5,000 for2008 and thereafter. For individuals who have reached the age of 50before the close of the tax year, the contribution limit is increased to$3,500 per year for tax years 2002 through 2004, $4,500 for 2005, $5,000for 2006 and 2007, and $6,000 for 2008 and thereafter. For tax years after2008, the above limits will be increased to reflect a cost‐of‐livingadjustment, if any.

ARTICLE II1. The annual contribution limit described in Article I is gradually reduced

to $0 for higher income levels. For a single depositor, the annualcontribution is phased out between adjusted gross income (AGI) of$95,000 and $110,000; for a married depositor filing jointly, betweenAGI of $150,000 and $160,000; and for a married depositor filingseparately, between AGI of $0 and $10,000. In the case of a conversion,the custodian will not accept IRA conversion contributions in a tax yearif the depositor’s AGI for the tax year the funds were distributed fromthe other IRA exceeds $100,000 or if the depositor is married and filesa separate return. Adjusted gross income is defined in section408A(c)(3) and does not include IRA conversion contributions.

2. In the case of a joint return, the AGI limits in the preceding paragraphapply to the combined AGI of the depositor and his or her spouse.

ARTICLE IIIThe depositor’s interest in the balance in the custodial account isnonforfeitable.

ARTICLE IV1. No part of the custodial account funds may be invested in life

insurance contracts, nor may the assets of the custodial account becommingled with other property except in a common trust fund orcommon investment fund (within the meaning of section 408(a)(5)).

2. No part of the custodial account funds may be invested in collectibles(within the meaning of section 408(m)) except as otherwise permittedby section 408(m)(3), which provides an exception for certain gold,silver, and platinum coins, coins issued under the laws of any state, andcertain bullion.

ARTICLE V1. If the depositor dies before his or her entire interest is distributed to

him or her and the depositor’s surviving spouse is not the designatedbeneficiary, the remaining interest will be distributed in accordancewith (a) below or, if elected or there is no designated beneficiary, inaccordance with (b) below:

(a) The remaining interest will be distributed, starting by the end ofthe calendar year following the year of the depositor’s death, overthe designated beneficiary’s remaining life expectancy asdetermined in the year following the death of the depositor.

(b) The remaining interest will be distributed by the end of thecalendar year containing the fifth anniversary of the depositor’sdeath.

2. The minimum amount that must be distributed each year underparagraph 1(a) above is the account value at the close of business onDecember 31 of the preceding year divided by the life expectancy (inthe single life table in Regulations section 1.401(a)(9)‐9) of thedesignated beneficiary using the attained age of the beneficiary in theyear following the year of the depositor’s death and subtracting 1 fromthe divisor for each subsequent year.

3. If the depositor’s surviving spouse is the designated beneficiary, suchspouse will then be treated as the depositor.

ARTICLE VI1. The depositor agrees to provide the custodian with all information

necessary to prepare any reports required by sections 408(i) and408A(d)(3)(E), Regulations sections 1.408‐5 and 1.408‐6, or otherguidance published by the Internal Revenue Service (IRS).

2. The custodian agrees to submit to the IRS and depositor the reportsprescribed by the IRS.

ARTICLE VIINotwithstanding any other articles which may be added or incorporated,the provisions of Articles I through IV and this sentence will be controlling.Any additional articles inconsistent with section 408A, the relatedregulations, and other published guidance will be invalid.

ARTICLE VIIIThis agreement will be amended as necessary to comply with theprovisions of the Code, the related Regulations, and other publishedguidance. Other amendments may be made with the consent of thepersons whose signatures appear on the application.

ARTICLE IX9.01 Definitions – In this part of this agreement (Article IX), the words

“you” and “your” mean the depositor. The words “we,” “us,” and“our” mean the custodian. The word “Code” means the InternalRevenue Code, and “regulations” means the Treasury regulations.

9.02 Notices and Change of Address – Any required notice regardingthis Roth IRA will be considered effective when we send it to theintended recipient at the last address that we have in our records.Any notice to be given to us will be considered effective when weactually receive it. You, or the intended recipient, must notify us ofany change of address.

9.03 Representations and Responsibilities – You represent and warrantto us that any information you have given or will give us withrespect to this agreement is complete and accurate. Further, youagree that any directions you give us or action you take will beproper under this agreement, and that we are entitled to rely uponany such information or directions. If we fail to receive directionsfrom you regarding any transaction, if we receive ambiguousdirections regarding any transaction, or if we, in good faith, believethat any transaction requested is in dispute, we reserve the right totake no action until further clarification acceptable to us is receivedfrom you or the appropriate government or judicial authority. We

ROTH INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT AGREEMENTForm 5305‐RA under section 408A of the Internal Revenue Code. FORM (Rev. March 2002)

Page 8 of 15

will not be responsible for losses of any kind that may result fromyour directions to us or your actions or failures to act, and youagree to reimburse us for any loss we may incur as a result of suchdirections, actions, or failures to act. We will not be responsible forany penalties, taxes, judgments, or expenses you incur inconnection with your Roth IRA. We have no duty to determinewhether your contributions or distributions comply with the Code,regulations, rulings, or this agreement.

We may permit you to appoint, through written notice acceptableto us, an authorized agent to act on your behalf with respect to thisagreement (e.g., attorney‐in‐fact, executor, administrator,investment manager), but we have no duty to determine thevalidity of such appointment or any instrument appointing suchauthorized agent. We will not be responsible for losses of any kindthat may result from directions, actions, or failures to act by yourauthorized agent, and you agree to reimburse us for any loss wemay incur as a result of such directions, actions, or failures to act byyour authorized agent.

You will have 60 days after you receive any documents, statements,or other information from us to notify us in writing of any errors orinaccuracies reflected in these documents, statements, or otherinformation. If you do not notify us within 60 days, the documents,statements, or other information will be deemed correct andaccurate, and we will have no further liability or obligation for suchdocuments, statements, other information, or the transactionsdescribed therein.

By performing services under this agreement we are acting as youragent. You acknowledge and agree that nothing in this agreementwill be construed as conferring fiduciary status upon us. We will notbe required to perform any additional services unless specificallyagreed to under the terms and conditions of this agreement, or asrequired under the Code and the regulations promulgatedthereunder with respect to Roth IRAs. You agree to indemnify andhold us harmless for any and all claims, actions, proceedings,damages, judgments, liabilities, costs, and expenses, includingattorney’s fees arising from or in connection with this agreement.

To the extent written instructions or notices are required under thisagreement, we may accept or provide such information in anyother form permitted by the Code or applicable regulationsincluding, but not limited to, electronic communication.

9.04 Disclosure of Account Information – We may use agents and/orsubcontractors to assist in administering your Roth IRA. We mayrelease nonpublic personal information regarding your Roth IRA tosuch providers as necessary to provide the products and servicesmade available under this agreement, and to evaluate our businessoperations and analyze potential product, service, or processimprovements.

9.05 Service Fees – We have the right to charge an annual service fee orother designated fees (e.g., a transfer, rollover, or termination fee)for maintaining your Roth IRA. In addition, we have the right to bereimbursed for all reasonable expenses, including legal expenses,we incur in connection with the administration of your Roth IRA.We may charge you separately for any fees or expenses, or we maydeduct the amount of the fees or expenses from the assets in yourRoth IRA at our discretion. We reserve the right to charge anyadditional fee after giving you 30 days’ notice. Fees such assubtransfer agent fees or commissions may be paid to us by thirdparties for assistance in performing certain transactions withrespect to this Roth IRA.

Any brokerage commissions attributable to the assets in your RothIRA will be charged to your Roth IRA. You cannot reimburse yourRoth IRA for those commissions.

9.06 Investment of Amounts in the IRA – You have exclusiveresponsibility for and control over the investment of the assets ofyour IRA. All investment transactions, including the reinvestment ofdividends, interest, and proceeds from securities sales, shall bedirected by you. Absent or pending such direction, we shall beentitled on a daily basis to sweep all IRA account balances. Suchbalances shall be invested in short‐term investments, which shallinclude insured savings accounts, insured savings certificates,federal funds, insured money market accounts, governmentsecurities, federal agency securities, and treasury notes, bonds andbills in which book value and interest is guaranteed (including any ofthe foregoing offered by Happy State Bank) (“TemporaryInvestments”). We shall have all power and authority necessary tohold, administer, vote and negotiate such Temporary Investment soas to enforce every right and benefit thereunder on your behalf. Inmaking all Temporary Investments, we shall not be limited toinvestments now or hereinafter designated by statute or decision ofa court as “legal investments” for funds held by fiduciaries. Youhereby agree that we may, but shall not be required (unless requiredunder applicable law) to inform you by forwarding materials orotherwise communicating with you under the provisions of ArticleVIII as to any questions, decisions or other matters for which a votemay be requested, necessary or helpful as to any TemporaryInvestment, and we shall thereafter have no responsibilitywhatsoever with respect thereto. You agree and acknowledge thatunless required by applicable law, we are not responsible forcommunicating, forwarding, or notifying any party, including you,with respect to any communication or matter which comes to theattention of or is received by us with respect to Trust investments,including Temporary Investments, and that you are responsible formaking separate arrangements for receiving such communications.

9.07 Beneficiaries – If you die before you receive all of the amounts inyour Roth IRA, payments from your Roth IRA will be made to yourbeneficiaries. We have no obligation to pay to your beneficiariesuntil such time we are notified of your death by receiving a validdeath certificate.

You may designate one or more persons or entities as beneficiaryof your Roth IRA. This designation can only be made on a formprovided by or acceptable to us, and it will only be effective whenit is filed with us during your lifetime. Each beneficiary designationyou file with us will cancel all previous designations. The consent ofyour beneficiaries will not be required for you to revoke abeneficiary designation. If you have designated both primary andcontingent beneficiaries and no primary beneficiary survives you,the contingent beneficiaries will acquire the designated share ofyour Roth IRA. If you do not designate a beneficiary or if all of yourprimary and contingent beneficiaries predecease you, your estatewill be the beneficiary.

If your surviving spouse is the designated beneficiary, your spousemay elect to treat your Roth IRA as his or her own Roth IRA, andwould not be subject to the required minimum distribution rules.Your surviving spouse will also be entitled to such additionalbeneficiary payment options as are granted under the Code orapplicable regulations.

We may allow, if permitted by state law, an original Roth IRAbeneficiary (the beneficiary who is entitled to receive distributionsfrom an inherited Roth IRA at the time of your death) to namesuccessor beneficiaries for the inherited Roth IRA. This designationcan only be made on a form provided by or acceptable to us, and itwill only be effective when it is filed with us during the original RothIRA beneficiary’s lifetime. Each beneficiary designation form thatthe original Roth IRA beneficiary files with us will cancel all previousdesignations. The consent of a successor beneficiary will not be

Page 9 of 15

required for the original Roth IRA beneficiary to revoke a successorbeneficiary designation. If the original Roth IRA beneficiary does notdesignate a successor beneficiary, his or her estate will be thesuccessor beneficiary. In no event will the successor beneficiary beable to extend the distribution period beyond that required for theoriginal Roth IRA beneficiary.

If we so choose, for any reason (e.g., due to limitations of ourcharter or bylaws), we may require that a beneficiary of a deceasedRoth IRA owner take total distribution of all Roth IRA assets byDecember 31 of the year following the year of death.

9.08 Termination of Agreement, Resignation, or Removal of Custodian –Either party may terminate this agreement at any time by givingwritten notice to the other. We can resign as custodian at any timeeffective 30 days after we send written notice of our resignation toyou. Upon receipt of that notice, you must make arrangements totransfer your Roth IRA to another financial organization. If you donot complete a transfer of your Roth IRA within 30 days from thedate we send the notice to you, we have the right to transfer yourRoth IRA assets to a successor Roth IRA trustee or custodian that wechoose in our sole discretion, or we may pay your Roth IRA to youin a single sum. We will not be liable for any actions or failures toact on the part of any successor trustee or custodian, nor for anytax consequences you may incur that result from the transfer ordistribution of your assets pursuant to this section.

If this agreement is terminated, we may charge to your Roth IRA areasonable amount of money that we believe is necessary to coverany associated costs, including but not limited to one or more of thefollowing.

• Any fees, expenses, or taxes chargeable against your Roth IRA• Any penalties or surrender charges associated with the early

withdrawal of any savings instrument or other investment inyour Roth IRA

If we are a nonbank custodian required to comply with Regulationssection 1.408‐2(e) and we fail to do so or we are not keeping therecords, making the returns, or sending the statements as arerequired by forms or regulations, the IRS may require us tosubstitute another trustee or custodian.

We may establish a policy requiring distribution of the entirebalance of your Roth IRA to you in cash or property if the balance ofyour Roth IRA drops below the minimum balance required underthe applicable investment or policy established.

9.09 Successor Custodian – If our organization changes its name,reorganizes, merges with another organization (or comes under thecontrol of any federal or state agency), or if our entire organization(or any portion that includes your Roth IRA) is bought by anotherorganization, that organization (or agency) will automaticallybecome the trustee or custodian of your Roth IRA, but only if it isthe type of organization authorized to serve as a Roth IRA trusteeor custodian.

9.10 Amendments – We have the right to amend this agreement at anytime. Any amendment we make to comply with the Code andrelated regulations does not require your consent. You will bedeemed to have consented to any other amendment unless, within30 days from the date we send the amendment, you notify us inwriting that you do not consent.

9.11 Withdrawals or Transfers – All requests for withdrawal or transferwill be in writing on a form provided by or acceptable to us. Themethod of distribution must be specified in writing or in any othermethod acceptable to us. The tax identification number of therecipient must be provided to us before we are obligated to makea distribution. Withdrawals will be subject to all applicable tax andother laws and regulations, including but not limited to possibleearly distribution penalty taxes, surrender charges, and withholdingrequirements.

You are not required to take a distribution from your Roth IRA atage 701⁄2. At your death, however, your beneficiaries must begintaking distributions in accordance with Article V and section 9.07 ofthis article. We will make no distributions to you from your Roth IRAuntil you provide us with a written request for a distribution on aform provided by or acceptable to us.

9.12 Transfers From Other Plans – We can receive amounts transferredto this Roth IRA from the trustee or custodian of another Roth IRAas permitted by the Code. In addition, we can accept rollovers ofeligible rollover distributions from employer‐sponsored retirementplans as permitted by the Code. We reserve the right not to acceptany transfer.

9.13 Liquidation of Assets – We have the right to liquidate assets in yourRoth IRA if necessary to make distributions or to pay fees, expenses,taxes, penalties, or surrender charges properly chargeable againstyour Roth IRA. If you fail to direct us as to which assets to liquidate,we will decide, in our complete and sole discretion, and you agreeto not hold us liable for any adverse consequences that result fromour decision.

9.14 Restrictions on the Fund – Neither you nor any beneficiary maysell, transfer, or pledge any interest in your Roth IRA in any mannerwhatsoever, except as provided by law or this agreement.

The assets in your Roth IRA will not be responsible for the debts,contracts, or torts of any person entitled to distributions under thisagreement.

9.15 What Law Applies – This agreement is subject to all applicablefederal and state laws and regulations. If it is necessary to apply anystate law to interpret and administer this agreement, the law of ourdomicile will govern.

If any part of this agreement is held to be illegal or invalid, theremaining parts will not be affected. Neither your nor our failure toenforce at any time or for any period of time any of the provisionsof this agreement will be construed as a waiver of such provisions,or your right or our right thereafter to enforce each and every suchprovision.

9.16 Broker – The Broker will be responsible for the execution of securitiesorders. The Broker may require that you sign an agreement whichsets forth, among other things, its responsibilities and yourresponsibilities regarding securities transactions for your Roth IRA.

9.17 Prohibited Transaction – If during any taxable year you engage in aso‐called “prohibited transaction” with respect to your regular RothIRA, Spousal Roth IRA, or Rollover Roth IRA, the account will lose itstax‐exempt status. In this event, the fair market value of all accountassets, valued as of the first day of such taxable year, will bedeemed distributed to you and includible in your gross income.These prohibited transactions would include borrowing moneyfrom your account or pledging your account or any portion thereofas security for a loan. If you pledge your account or any portionthereof as security for a loan, such pledge position will be deemeddistributed to you and includible in your gross income. If you havenot yet attained age fifty‐nine and one‐half (591⁄2) years of age, anadditional excise tax equal to ten percent (10%) of the amount

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pledged will be imposed on such funds includible in gross income.Similarly, if your spouse engages in a prohibited transaction withrespect to his or her account, it will result in the sameconsequences because he or she is the individual for whose benefitthe account was established.The assets in your Roth IRA shall notbe responsible for the debt, contracts or torts of any personentitled to distributions under this Agreement.

9.18 Mediation/Arbitration – If a dispute arises out of or relates to thisagreement, or the performance or breach thereof, the partiesagree first to try in good faith to settle the dispute by mediationunder the commercial mediation rules of the American ArbitrationAssociation, before resorting the arbitration. Thereafter, anyremaining unresolved controversy or claim arising out of or relatingto this agreement, or the performance or breach thereof, shall besettled by arbitration in accordance with the commercialarbitration rules of the American Arbitration Association. Anymediation or arbitration shall be conducted in Canyon, TX. The solearbitrator shall be a retired or former judge of the Randall or PotterCounty District Courts. Judgement upon the award rendered by thearbitrator may be entered in any court having jurisdiction thereof.

GENERAL INSTRUCTIONS

Section references are to the Internal Revenue Code unless otherwise noted.

PURPOSE OF FORMForm 5305‐RA is a model custodial account agreement that meets therequirements of section 408A and has been pre‐approved by the IRS. ARoth individual retirement account (Roth IRA) is established after the formis fully executed by both the individual (depositor) and the custodian. Thisaccount must be created in the United States for the exclusive benefit ofthe depositor and his or her beneficiaries.

Do not file Form 5305‐RA with the IRS. Instead, keep it with your records.

Unlike contributions to Traditional individual retirement arrangements,contributions to a Roth IRA are not deductible from the depositor’s grossincome; and distributions after 5 years that are made when the depositoris 591⁄2 years of age or older or on account of death, disability, or thepurchase of a home by a first‐time homebuyer (limited to $10,000), arenot includible in gross income. For more information on Roth IRAs,including the required disclosures the custodian must give the depositor,see Pub. 590, Individual Retirement Arrangements (IRAs).

DEFINITIONSIRA Conversion Contributions – IRA conversion contributions are amountsrolled over, transferred, or considered transferred from a nonRoth IRA toa Roth IRA. A nonRoth IRA is an individual retirement account or annuitydescribed in section 408(a) or 408(b), other than a Roth IRA.

Custodian – The custodian must be a bank or savings and loan association,as defined in section 408(n), or any person who has the approval of the IRSto act as custodian.

Depositor – The depositor is the person who establishes the custodialaccount.

SPECIFIC INSTRUCTIONS

Article I – The depositor may be subject to a 6% tax on excesscontributions if (1) contributions to other individual retirementarrangements of the depositor have been made for the same tax year, (2)the depositor’s adjusted gross income exceeds the applicable limits inArticle II for the tax year, or (3) the depositor’s and spouse’s compensationis less than the amount contributed by or on behalf of them for the taxyear. The depositor should see the disclosure statement or Pub. 590 formore information.

Article V – This article describes how distributions will be made from theRoth IRA after the depositor’s death. Elections made pursuant to thisarticle should be reviewed periodically to ensure they correspond to thedepositor’s intent. Under paragraph 3 of Article V, the depositor’s spouseis treated as the owner of the Roth IRA upon the death of the depositor,rather than as the beneficiary. If the spouse is to be treated as thebeneficiary and not the owner, an overriding provision should be added toArticle IX.

Article IX – Article IX and any that follow it may incorporate additionalprovisions that are agreed to by the depositor and custodian to completethe agreement. They may include, for example, definitions, investmentpowers, voting rights, exculpatory provisions, amendment andtermination, removal of the custodian, custodian’s fees, state lawrequirements, beginning date of distributions, accepting only cash,treatment of excess contributions, prohibited transactions with thedepositor, etc. Attach additional pages if necessary.

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RIGHT TO REVOKE YOUR ROTH IRAYou have the right to revoke your Roth IRA within seven days of thereceipt of the disclosure statement. If revoked, you are entitled to a fullreturn of the contribution you made to your Roth IRA. The amountreturned to you would not include an adjustment for such items as salescommissions, administrative expenses, or fluctuation in market value. Youmay make this revocation only by mailing or delivering a written notice tothe custodian at the address listed on the application.

If you send your notice by first class mail, your revocation will be deemedmailed as of the postmark date.

If you have any questions about the procedure for revoking your Roth IRA,please call the custodian at the telephone number listed on theapplication.

REQUIREMENTS OF A ROTH IRAA. Cash Contributions – Your contribution must be in cash, unless it is a

rollover or conversion contribution.

B. Maximum Contribution – The total amount you may contribute to aRoth IRA for any taxable year cannot exceed the lesser of 100 percentof your compensation or $5,500 for 2014 and 2015, with possible cost‐of‐living adjustments each year thereafter. If you also maintain aTraditional IRA (i.e., an IRA subject to the limits of Internal RevenueCode Sections (IRC Secs.) 408(a) or 408(b)), the maximum contributionto your Roth IRAs is reduced by any contributions you make to yourTraditional IRAs. Your total annual contribution to all Roth IRAs andTraditional IRAs cannot exceed the lesser of the dollar amountsdescribed above or 100 percent of your compensation.

Your Roth IRA contribution is further limited if your modified adjustedgross income (MAGI) equals or exceeds $181,000 (for 2014) or$183,000 (for 2015) if you are a married individual filing a joint incometax return, or equals or exceeds $114,000 (for 2014) or $116,000 (for2015) if you are a single individual. Married individuals filing a jointincome tax return with MAGI equaling or exceeding $191,000 (for2014) or $193,000 (for 2015) may not fund a Roth IRA. Singleindividuals with MAGI equaling or exceeding $129,000 (for 2014) or$131,000 (for 2015) may not fund a Roth IRA. Married individuals filinga separate income tax return with MAGI equaling or exceeding $10,000may not fund a Roth IRA. The MAGI limits described above are subjectto cost‐of‐living increases for tax years beginning after 2015.

If you are married filing a joint income tax return and your MAGI isbetween the applicable MAGI phase‐out range for the year, yourmaximum Roth IRA contribution is determined as follows. (1) Beginwith the appropriate MAGI phase‐out maximum for the applicable yearand subtract your MAGI; (2) divide this total by the difference betweenthe phase‐out range maximum and minimum; and (3) multiply thisnumber by the maximum allowable contribution for the applicableyear, including catch‐up contributions if you are age 50 or older. Forexample, if you are age 30 with MAGI of $188,000, your maximumRoth IRA contribution for 2015 is $2,750 ([$193,000 minus $188,000]divided by $10,000 and multiplied by $5,500).

If you are single and your MAGI is between the applicable MAGI phase‐out for the year, your maximum Roth IRA contribution is determined asfollows. (1) Begin with the appropriate MAGI phase‐out maximum forthe applicable year and subtract your MAGI; (2) divide this total by thedifference between the phase‐out range maximum and minimum; and(3) multiply this number by the maximum allowable contribution forthe applicable year, including catch‐up contributions if you are age 50or older. For example, if you are age 30 with MAGI of $119,000, yourmaximum Roth IRA contribution for 2015 is $4,400 ([$131,000 minus$119,000] divided by $15,000 and multiplied by $5,500).

C. Contribution Eligibility – You are eligible to make a regularcontribution to your Roth IRA, regardless of your age, if you havecompensation and your MAGI is below the maximum threshold. YourRoth IRA contribution is not limited by your participation in anemployer‐sponsored retirement plan, other than a Traditional IRA.

D. Catch‐Up Contributions – If you are age 50 or older by the close of thetaxable year, you may make an additional contribution to your RothIRA. The maximum additional contribution is $1,000 per year.

E. Nonforfeitability – Your interest in your Roth IRA is nonforfeitable.

F. Eligible Custodians – The custodian of your Roth IRA must be a bank,savings and loan association, credit union, or a person or entityapproved by the Secretary of the Treasury.

G. Commingling Assets – The assets of your Roth IRA cannot becommingled with other property except in a common trust fund orcommon investment fund.

H. Life Insurance – No portion of your Roth IRA may be invested in lifeinsurance contracts.

I. Collectibles – You may not invest the assets of your Roth IRA incollectibles (within the meaning of IRC Sec. 408(m)). A collectible isdefined as any work of art, rug or antique, metal or gem, stamp or coin,alcoholic beverage, or other tangible personal property specified bythe Internal Revenue Service (IRS). However, specially minted UnitedStates gold and silver coins, and certain state‐issued coins arepermissible investments. Platinum coins and certain gold, silver,platinum, or palladium bullion (as described in IRC Sec. 408(m)(3)) arealso permitted as Roth IRA investments.

J. Beneficiary Payouts – Your designated beneficiary is determinedbased on the beneficiaries designated as of the date of your death,who remain your beneficiaries as of September 30 of the yearfollowing the year of your death. The entire amount remaining in youraccount will, at the election of your designated beneficiaries, either

1. be distributed by December 31 of the year containing the fifthanniversary of your death, or

2. be distributed over the remaining life expectancy of your designatedbeneficiaries.

If your spouse is your sole designated beneficiary, he or she must electeither option (1) or (2) by the earlier of December 31 of the yearcontaining the fifth anniversary of your death, or December 31 of theyear life expectancy payments would be required to begin. Yourdesignated beneficiaries, other than a spouse who is the soledesignated beneficiary, must elect either option (1) or (2) by December31 of the year following the year of your death. If no election is made,distribution will be calculated in accordance with option (2). In the caseof distributions under option (2), distributions must commence byDecember 31 of the year following the year of your death. Generally, ifyour spouse is the designated beneficiary, distributions need notcommence until December 31 of the year you would have attained age701⁄2, if later. If a beneficiary other than a person or qualified trust asdefined in the Treasury Regulations is named, you will be treated ashaving no designated beneficiary of your Roth IRA for purposes ofdetermining the distribution period. If there is no designatedbeneficiary of your Roth IRA, the entire Roth IRA must be distributed byDecember 31 of the year containing the fifth anniversary of your death.

DISCLOSURE STATEMENT

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A spouse who is the sole designated beneficiary of your entire Roth IRAwill be deemed to elect to treat your Roth IRA as his or her own byeither (1) making contributions to your Roth IRA or (2) failing to timelyremove a required minimum distribution from your Roth IRA.Regardless of whether or not the spouse is the sole designatedbeneficiary of your Roth IRA, a spouse beneficiary may roll over his orher share of the assets to his or her own Roth IRA.

If we so choose, for any reason (e.g., due to limitations of our charteror bylaws), we may require that a beneficiary of a deceased Roth IRAowner take total distribution of all Roth IRA assets by December 31 ofthe year following the year of death.

If your beneficiary fails to remove a required minimum distributionafter your death, an additional penalty tax of 50 percent is imposed onthe amount of the required minimum distribution that should havebeen taken but was not. Your beneficiary must file IRS Form 5329 alongwith his or her income tax return to report and remit any additionaltaxes to the IRS.

INCOME TAX CONSEQUENCES OF ESTABLISHING A ROTH IRAA. Contributions Not Deducted – No deduction is allowed for Roth IRA

contributions, including transfers, rollovers, and conversioncontributions.

B. Contribution Deadline – The deadline for making a Roth IRAcontribution is your tax return due date (not including extensions). Youmay designate a contribution as a contribution for the precedingtaxable year in a manner acceptable to us. For example, if you are acalendar‐year taxpayer and you make your Roth IRA contribution on orbefore your tax filing deadline, your contribution is considered to havebeen made for the previous tax year if you designate it as such.

If you are a member of the Armed Forces serving in a combat zone,hazardous duty area, or contingency operation, you may have anextended contribution deadline of 180 days after the last day served inthe area. In addition, your contribution deadline for a particular taxyear is also extended by the number of days that remained to file thatyear’s tax return as of the date you entered the combat zone. Thisadditional extension to make your Roth IRA contribution cannotexceed the number of days between January 1 and your tax filingdeadline, not including extensions.

C. Tax Credit for Contributions – You may be eligible to receive a taxcredit for your Roth IRA contributions. This credit may not exceed$1,000 in a given year. You may be eligible for this tax credit if you are

• age 18 or older as of the close of the taxable year,• not a dependent of another taxpayer, and• not a full‐time student.

The credit is based upon your income (see chart below), and will rangefrom 0 to 50 percent of eligible contributions. In order to determinethe amount of your contributions, add all of the contributions made toyour Roth IRA and reduce these contributions by any distributions thatyou have taken during the testing period. The testing period beginstwo years prior to the year for that the credit is sought and ends on thetax return due date (including extensions) for the year for that thecredit is sought. In order to determine your tax credit, multiply theapplicable percentage from the chart below by the amount of yourcontributions that do not exceed $2,000.

2015 Adjusted Gross Income*

Joint Head of a All OtherApplicable

Return Household CasesPercentage

$1 – 36,500 $1 – 27,375 $1 – 18,250 50$36,501 – 39,500 $27,376 – 29,625 $18,251 – 19,750 20$39,501 – 61,000 $29,626 – 45,750 $19,751 – 30,500 10

Over $61,000 Over $45,750 Over $30,500 0

*Adjusted gross income (AGI) includes foreign earned income andincome from Guam, America Samoa, North Mariana Islands, and PuertoRico. AGI limits are subject to cost‐of‐living adjustments each year.

D. Excess Contributions – An excess contribution is any amount that iscontributed to your Roth IRA that exceeds the amount that you areeligible to contribute. If the excess is not corrected timely, anadditional penalty tax of six percent will be imposed upon the excessamount. The procedure for correcting an excess is determined by thetimeliness of the correction as identified below.

1. Removal Before Your Tax Filing Deadline. An excess contributionmay be corrected by withdrawing the excess amount, along withthe earnings attributable to the excess, before your tax filingdeadline, including extensions, for the year for which the excesscontribution was made. An excess withdrawn under this method isnot taxable to you, but you must include the earnings attributableto the excess in your taxable income in the year in which thecontribution was made. The six percent excess contribution penaltytax will be avoided.

2. Removal After Your Tax Filing Deadline. If you are correcting anexcess contribution after your tax filing deadline, includingextensions, remove only the amount of the excess contribution.The six percent excess contribution penalty tax will be imposed onthe excess contribution for each year it remains in the Roth IRA. Anexcess withdrawal under this method is not taxable to you.

3. Carry Forward to a Subsequent Year. If you do not withdraw theexcess contribution, you may carry forward the contribution for asubsequent tax year. To do so, you under‐contribute for that taxyear and carry the excess contribution amount forward to that yearon your tax return. The six percent excess contribution penalty taxwill be imposed on the excess amount for each year that it remainsas an excess contribution at the end of the year.

You must file IRS Form 5329 along with your income tax return toreport and remit any additional taxes to the IRS.

E. Tax‐Deferred Earnings – The investment earnings of your Roth IRA arenot subject to federal income tax as they accumulate in your Roth IRA.In addition, distributions of your Roth IRA earnings will be free fromfederal income tax if you take a qualified distribution, as describedbelow.

F. Taxation of Distributions – The taxation of Roth IRA distributionsdepends on whether the distribution is a qualified distribution or anonqualified distribution.

1. Qualified Distributions. Qualified distributions from your Roth IRA(both the contributions and earnings) are not included in yourincome. A qualified distribution is a distribution that is made afterthe expiration of the five‐year period beginning January 1 of thefirst year for which you made a contribution to any Roth IRA(including a conversion from a Traditional IRA), and is made onaccount of one of the following events.

• Attainment of age 591⁄2

• Disability• First‐time homebuyer purchase• Death

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For example, if you made a contribution to your Roth IRA for 2007,the five‐year period for determining whether a distribution is aqualified distribution is satisfied as of January 1, 2012.

2. Nonqualified Distributions. If you do not meet the requirementsfor a qualified distribution, any earnings you withdraw from yourRoth IRA will be included in your gross income and, if you are underage 591⁄2, may be subject to an early distribution penalty tax.However, when you take a distribution, the amounts youcontributed annually to any Roth IRA and any military deathgratuity or Servicemembers’ Group Life Insurance (SGLI) paymentsthat you rolled over to a Roth IRA, will be deemed to be removedfirst, followed by conversion and employer‐sponsored retirementplan rollover contributions made to any Roth IRA on a first‐in, first‐out basis. Therefore, your nonqualified distributions will not betaxable to you until your withdrawals exceed the amount of yourannual contributions, rollovers of your military death gratuity orSGLI payments, and your conversions and employer‐sponsoredretirement plan rollovers.

G. Income Tax Withholding – Any nonqualified withdrawal of earningsfrom your Roth IRA may be subject to federal income tax withholding.You may, however, elect not to have withholding apply to your RothIRA withdrawal. If withholding is applied to your withdrawal, not lessthan 10 percent of the amount withdrawn must be withheld.

H. Early Distribution Penalty Tax – If you are under age 591⁄2 and receive anonqualified Roth IRA distribution, an additional early distributionpenalty tax of 10 percent generally will apply to the amount includiblein income in the year of the distribution. If you are under age 591⁄2 andreceive a distribution of conversion amounts or employer‐sponsoredretirement plan rollover amounts within the five‐year period beginningwith the year in which the conversion or employer‐sponsoredretirement plan rollover occurred, an additional early distributionpenalty tax of 10 percent generally will apply to the amount of thedistribution. The additional early distribution penalty tax of 10 percentgenerally will not apply if one of the following exceptions apply.1) Death. After your death, payments made to your beneficiary are notsubject to the 10 percent early distribution penalty tax. 2) Disability. Ifyou are disabled at the time of distribution, you are not subject to theadditional 10 percent early distribution penalty tax. In order to bedisabled, a physician must determine that your impairment can beexpected to result in death or to be of long, continued, and indefiniteduration. 3) Substantially equal periodic payments. You are notsubject to the additional 10 percent early distribution penalty tax if youare taking a series of substantially equal periodic payments (at leastannual payments) over your life expectancy or the joint life expectancyof you and your beneficiary. You must continue these payments for thelonger of five years or until you reach age 591⁄2. 4) Unreimbursedmedical expenses. If you take payments to pay for unreimbursedmedical expenses exceeding 10 percent of your adjusted gross income,you will not be subject to the 10 percent early distribution penalty tax.The medical expenses may be for you, your spouse, or any dependentlisted on your tax return. 5) Health insurance premiums. If you areunemployed and have received unemployment compensation for 12consecutive weeks under a federal or state program, you may takepayments from your Roth IRA to pay for health insurance premiumswithout incurring the 10 percent early distribution penalty tax.6) Higher education expenses. Payments taken for certain qualifiedhigher education expenses for you, your spouse, or the children orgrandchildren of you or your spouse, will not be subject to the 10percent early distribution penalty tax. 7) First‐time homebuyer. Youmay take payments from your Roth IRA to use toward qualifiedacquisition costs of buying or building a principle residence. Theamount you may take for this reason may not exceed a lifetimemaximum of $10,000. The payment must be used for qualifiedacquisition costs within 120 days of receiving the distribution. 8) IRS

levy. Payments from your Roth IRA made to the U.S. government inresponse to a federal tax levy are not subject to the 10 percent earlydistribution penalty tax. 9) Qualified reservist distributions. If you area qualified reservist member called to active duty for more than 179days or an indefinite period, the payments you take from your Roth IRAduring the active duty period are not subject to the 10 percent earlydistribution penalty tax.

You must file IRS Form 5329 along with your income tax return to theIRS to report and remit any additional taxes or to claim a penalty taxexception.

I. Required Minimum Distributions – You are not required to takedistributions from your Roth IRA at age 701⁄2 (as required for Traditionaland savings incentive match plan for employees of small employers(SIMPLE) IRAs). However, your beneficiaries generally are required totake distributions from your Roth IRA after your death. See the sectiontitled Beneficiary Payouts in this disclosure statement regardingbeneficiaries’ required minimum distributions.

J. Rollovers and Conversions – Your Roth IRA may be rolled over toanother Roth IRA of yours, may receive rollover contributions, or mayreceive conversion contributions, provided that all of the applicablerollover or conversion rules are followed. Rollover is a term used todescribe a movement of cash or other property to your Roth IRA fromanother Roth IRA, or from your employer’s qualified retirement plan,403(a) annuity, 403(b) tax‐sheltered annuity, 457(b) eligiblegovernmental deferred compensation plan, or federal Thrift SavingsPlan. Conversion is a term used to describe the movement ofTraditional IRA or SIMPLE IRA assets to a Roth IRA. A conversiongenerally is a taxable event. The general rollover and conversion rulesare summarized below. These transactions are often complex. If youhave any questions regarding a rollover or conversion, please see acompetent tax advisor.

1. Roth IRA‐to‐Roth IRA Rollovers. Assets distributed from your RothIRA may be rolled over to the same Roth IRA or another Roth IRA ofyours if the requirements of IRC Sec. 408(d)(3) are met. A properRoth IRA‐to‐Roth IRA rollover is completed if all or part of thedistribution is rolled over not later than 60 days after thedistribution is received. In the case of a distribution for a first‐timehomebuyer where there was a delay or cancellation of thepurchase, the 60‐day rollover period may be extended to 120 days.Roth IRA assets may not be rolled over to other types of IRAs (e.g.,Traditional IRA, SIMPLE IRA), or employer‐sponsored retirementplans.

Effective for distributions taken on or after January 1, 2015, youare permitted to roll over only one distribution from an IRA(Traditional, Roth, or SIMPLE) in a 12‐month period, regardless ofthe number of IRAs you own. A distribution may be rolled over tothe same IRA or to another IRA that is eligible to receive therollover. For more information on rollover limitations, you maywish to obtain IRS Publication 590, Individual RetirementArrangements (IRAs), from the IRS or refer to the IRS website atwww.irs.gov.

2. Traditional IRA to Roth IRA Conversions. If you convert to a RothIRA, the amount of the conversion from your Traditional IRA to yourRoth IRA will be treated as a distribution for income tax purposes,and is includible in your gross income (except for any nondeductiblecontributions). Although the conversion amount generally isincluded in income, the 10 percent early distribution penalty taxwill not apply to conversions from a Traditional IRA to a Roth IRA,regardless of whether you qualify for any exceptions to the 10percent early distribution penalty tax. If you are age 701⁄2 or older,you must remove your required minimum distribution beforeconverting your Traditional IRA.

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3. SIMPLE IRA to Roth IRA Conversions. You are eligible to convert allor any portion of your existing SIMPLE IRA into your Roth IRA,provided two years have passed since you first participated in aSIMPLE IRA plan sponsored by your employer. The amount of theconversion from your SIMPLE IRA to your Roth IRA will be treatedas a distribution for income tax purposes and is includible in yourgross income. Although the conversion amount generally isincluded in income, the 10 percent early distribution penalty taxwill not apply to conversions from a SIMPLE IRA to a Roth IRA,regardless of whether you qualify for any exceptions to the 10percent early distribution penalty tax. If you are age 701⁄2 or olderyou must remove your required minimum distribution beforeconverting your SIMPLE IRA.

4. Rollovers of Roth Elective Deferrals. Roth elective deferralsdistributed from a 401(k) cash or deferred arrangement, 403(b) tax‐sheltered annuity, 457(b) eligible governmental deferredcompensation plan, or federal Thrift Savings Plan, may be rolledinto your Roth IRA.

5. Employer‐Sponsored Retirement Plan to Roth IRA Rollovers.Assets distributed from your qualified retirement plan, 403(a)annuity, 403(b) tax‐sheltered annuity, 457(b) eligible governmentaldeferred compensation plan, or federal Thrift Savings Plan may berolled over to your Roth IRA. If you are a spouse, nonspouse, orqualified trust beneficiary who has inherited a qualified retirementplan, 403(a) annuity, 403(b) tax‐sheltered annuity, or 457(b) eligiblegovernmental deferred compensation plan, you may be eligible todirectly roll over the assets to an inherited Roth IRA. The inheritedRoth IRA is subject to the beneficiary distribution requirements.Although the rollover amount generally is included in income, the10 percent early distribution penalty tax will not apply to rolloversfrom eligible employer‐sponsored retirement plans to a Roth IRA orinherited Roth IRA, regardless of whether you qualify for anyexceptions to the 10 percent early distribution penalty tax.

6. Beneficiary Rollovers From 401(k), 403(b), or 457(b) EligibleGovernmental Plans Containing Roth Elective Deferrals. If you area spouse, nonspouse, or qualified trust beneficiary of a deceased401(k), 403(b), or 457(b) eligible governmental deferredcompensation plan participant who had made Roth electivedeferrals to the plan, you may directly roll over the Roth electivedeferrals and their earnings to an inherited Roth IRA. The Roth IRAmust be maintained as an inherited Roth IRA, subject to thebeneficiary distribution requirements.

7. Rollovers of Military Death Benefits. If you receive or havereceived a military death gratuity or a payment from the SGLIprogram, you may be able to roll over the proceeds to your RothIRA. The rollover contribution amount is limited to the sum of thedeath benefits or SGLI payment received, less any such amount thatwas rolled over to a Coverdell education savings account. Proceedsmust be rolled over within one year of receipt of the gratuity or SGLIpayment for deaths occurring on or after June 17, 2008. Anyamount that is rolled over under this provision is considerednontaxable basis in your Roth IRA.

8. Qualified HSA Funding Distribution. If you are eligible tocontribute to a health savings account (HSA), you may be eligible totake a one‐time tax‐free qualified HSA funding distribution fromyour Roth IRA and directly deposit it to your HSA. The amount ofthe qualified HSA funding distribution may not exceed themaximum HSA contribution limit in effect for the type of highdeductible health plan coverage (i.e., single or family coverage) thatyou have at the time of the deposit, and counts toward your HSAcontribution limit for that year. For further detailed information,you may wish to obtain IRS Publication 969, Health SavingsAccounts and Other Tax‐Favored Health Plans.

9. Rollovers of Settlement Payments From Bankrupt Airlines. Ifyou are a qualified airline employee who has received an airlinesettlement payment from a commercial airline carrier under theapproval of an order of a federal bankruptcy court in a case filedafter September 11, 2001, and before January 1, 2007, you areallowed to roll over any portion of the proceeds into your RothIRA by the later of 180 days after receipt of such amount, or June21, 2009. To obtain more information on this type of rollover,you may wish to visit the IRS website at www.irs.gov.

10. Rollovers of Exxon Valdez Settlement Payments. If you receive aqualified settlement payment from Exxon Valdez litigation, you mayroll over the amount of the settlement, up to $100,000, reduced bythe amount of any qualified Exxon Valdez settlement incomepreviously contributed to a Traditional or Roth IRA or eligibleretirement plan in prior taxable years. You will have until your taxreturn due date (not including extensions) for the year in which thequalified settlement income is received to make the rollovercontribution. To obtain more information on this type of rollover,you may wish to visit the IRS website at www.irs.gov.

11. Written Election. At the time you make a rollover or conversion toa Roth IRA, you must designate in writing to the custodian yourelection to treat that contribution as a rollover or conversion. Oncemade, the election is irrevocable.

K. Transfer Due to Divorce – If all or any part of your Roth IRA is awardedto your spouse or former spouse in a divorce or legal separationproceeding, the amount so awarded will be treated as the spouse’sRoth IRA (and may be transferred pursuant to a court‐approveddivorce decree or written legal separation agreement to another RothIRA of your spouse), and will not be considered a taxable distributionto you. A transfer is a tax‐free direct movement of cash and/orproperty from one Roth IRA to another.

L. Recharacterizations – If you make a contribution to a Traditional IRAand later recharacterize either all or a portion of the originalcontribution to a Roth IRA along with net income attributable, you mayelect to treat the original contribution as having been made to the RothIRA. The same methodology applies when recharacterizing acontribution from a Roth IRA to a Traditional IRA. If you have convertedfrom a Traditional IRA to a Roth IRA you may recharacterize theconversion along with net income attributable back to a TraditionalIRA. If you have rolled over an eligible employer‐sponsored retirementplan to a Roth IRA, you may recharacterize the rollover amount alongwith net income attributable to a Traditional IRA. The deadline forcompleting a recharacterization is your tax filing deadline (includingany extensions) for the year for which the original contribution wasmade or conversion or rollover completed.

LIMITATIONS AND RESTRICTIONSA. Spousal Roth IRA – If you are married and have compensation, you

may contribute to a Roth IRA established for the benefit of yourspouse, regardless of whether or not your spouse has compensation.You must file a joint income tax return for the year for which thecontribution is made.

The amount you may contribute to your Roth IRA and your spouse’sRoth IRA is the lesser of 100 percent of your combined eligiblecompensation or $11,000 for 2014 and 2015. This amount may beincreased with cost‐of‐living adjustments each year. However, you maynot contribute more than the individual contribution limit to each RothIRA. Your contribution may be further limited if your MAGI falls withinthe minimum and maximum thresholds.

If your spouse is age 50 or older by the close of the taxable year, and isotherwise eligible, you may make an additional contribution to yourspouse’s Roth IRA. The maximum additional contribution is $1,000 peryear.

Page 15 of 15

B. Gift Tax – Transfers of your Roth IRA assets to a beneficiary madeduring your life and at your request may be subject to federal gift taxunder IRC Sec. 2501.

C. Special Tax Treatment – Capital gains treatment and 10‐year incomeaveraging authorized by IRC Sec. 402 do not apply to Roth IRAdistributions.

D. Prohibited Transactions – If you or your beneficiary engage in aprohibited transaction with your Roth IRA, as described in IRC Sec.4975, your Roth IRA will lose its tax‐deferred or tax‐exempt status, andyou generally must include the value of the earnings in your account inyour gross income for that taxable year. The following transactions areexamples of prohibited transactions with your Roth IRA. (1) Taking aloan from your Roth IRA (2) Buying property for personal use (presentor future) with Roth IRA assets (3) Receiving certain bonuses orpremiums because of your Roth IRA.

E. Pledging – If you pledge any portion of your Roth IRA as collateral fora loan, the amount so pledged will be treated as a distribution and maybe included in your gross income for that year.

OTHERA. IRS Plan Approval – The agreement used to establish this Roth IRA has

been approved by the IRS. The IRS approval is a determination only asto form. It is not an endorsement of the plan in operation or of theinvestments offered.

B. Additional Information – For further information on Roth IRAs, youmay wish to obtain IRS Publication 590, Individual RetirementArrangements (IRAs), by calling 1‐800‐TAX‐FORM, or by visitingwww.irs.gov on the Internet.

C. Important Information About Procedures for Opening a New Account –To help the government fight the funding of terrorism and moneylaundering activities, federal law requires all financial organizations toobtain, verify, and record information that identifies each person whoopens an account. Therefore, when you open a Roth IRA, you arerequired to provide your name, residential address, date of birth, andidentification number. We may require other information that willallow us to identify you.

D. Qualified Reservist Distributions – If you are an eligible qualifiedreservist who has taken penalty‐free qualified reservist distributionsfrom your Roth IRA or retirement plan, you may recontribute thoseamounts to a Roth IRA generally within a two‐year period from yourdate of return.

E. Qualified Charitable Distributions – If you are age 701⁄2 or older, youmay take tax‐free Roth IRA distributions of up to $100,000 per year andhave these distributions paid directly to certain charitableorganizations. Special tax rules may apply. This provision applies todistributions during tax years 2012 and 2013 and may apply tosubsequent years if extended by Congress. For further detailedinformation and effective dates you may wish to obtain IRS Publication590, Individual Retirement Arrangements (IRAs), from the IRS or referto the IRS website at www.irs.gov.

F. Disaster Related Relief – If you qualify (for example, you sustained aneconomic loss due to, or are otherwise considered affected by, certainIRS designated disasters), you may be eligible for favorable taxtreatment on distributions, rollovers, and other transactions involvingyour Roth IRA. Qualified disaster relief may include penalty‐tax freeearly distributions made during specified timeframes for each disaster,the ability to include distributions in your gross income ratably overmultiple years, the ability to roll over distributions to an eligibleretirement plan without regard to the 60‐day rollover rule, and more.For additional information on specific disasters, including a completelisting of disaster areas, qualification requirements for relief, andallowable disaster‐related Roth IRA transactions, you may wish toobtain IRS Publication 590, Individual Retirement Arrangements (IRAs),from the IRS or refer to the IRS website at www.irs.gov.

ROLLOVER TYPE AND ELIGIBILITY REQUIREMENTS

To be eligible for an IRA rollover type listed below, ALL statements for that rollover type must be true. By signing this form, you are certifying that all applicable statements are true. Refer to page 2 for rules and conditions that apply to rollover eligibility. CURRENT

GOLDSTAR IRA ACCOUNT OWNER

Name: ____________________________________________________ SSN: __________________ Date of Birth: ________________

Account #: _____________________________ Account Type: Tradtional IRA SEP IRA SIMPLE IRA Roth IRA

Address: ___________________________________________________ Daytime Phone #: __________________________________

__________________________________________________________ Email: ____________________________________________

P. O. Box 719 1401 4th Avenue

Canyon, TX 79015(800) 486-6888

NewBusiness@goldstartrust.com

IRA ROLLOVER CERTIFICATIOND

INSTRUCTIONS: Complete this form only when initiating a 60-day rollover of assets previously distributed to you from (1) an IRA at GoldStar, (2) another IRA or (3) from an employer-sponsored retirement plan. DO NOT use this form to transfer assets directly from an IRA.

I certify that all of the information provided by me is true and correct and may be relied upon by GoldStar Trust Company. I certify that I am eligible for the type of IRA rollover being made and that (i) all funds are being deposited within the allowable 60 day period since distributed to me, (ii) this is the only IRA to IRA rollover for or by me within the previous 12 month period, and (iii) none of the assets being deposited contain amounts from a Required Minimum Distribution. I have read and understand the rules and conditions on both pages of this form and I have met the requirements for making an IRA rollover. I assume full responsibility for this rollover transaction and will not hold GoldStar liable for any adverse consequences that may result. Due to the important tax consequences of rolling over funds or property to an IRA, I have been advised to see a tax professional.

I hereby designate this contribution of $__________________in cash and/or property as a rollover contribution.

X___________________________________________________________ ___________________ Account Holder’s Signature Date

AUTHORIZATION AND SIGNATURE

If this is a rollover from a SIMPLE IRA, the following statement must also be true:

I received the assets from the distributing IRA within the last 60 days.

This rollover contribution does not contain a required minimum distribution (RMD).

I have not rolled over any other distribution from any of my IRAs (Traditional, Roth or SIMPLE) within the last 12 months.

More than two years have passed since the first contribution to my SIMPLE IRA.

1.

2.

3.

4.

If the assets are not payable directly to your IRA, the following statement must also be true:

A

I am the plan participant, spouse beneficiary, alternate payee of a qualified domestic relations order, or nonspouse beneficiary of the plan participant.

This rollover contribution is from an eligible employer-sponsored plan.

This rollover contribution does not contain any ineligible rollover distributions.

I received the assets within the last 60 days.

DIRECT OR INDIRECT ROLLOVER FROM AN ELIGIBLE EMPLOYER-SPONSORED RETIREMENT PLAN

1.

2.

3.

4.

B

OR

Page 1 of 2GTC Rev 2015/03

ROLLOVER FROM A TRADITIONAL, ROTH, SEP OR SIMPLE IRA

RULES AND CONDITIONS APPLICABLE TO ROLLOVERS

• • •

• • • •

• • •

•

Page 2 of 2GTC Rev 2015/03

The IRA contribution and rollover rules are often complex. The general rules are listed below. If you have any questions regarding a contribu-tion or rollover, please consult with a competent tax professional or refer to IRS Publication 590, Individual Retirement Arrangements (IRAs), for more information. ROLLOVER FROM A TRADITIONAL, ROTH OR SIMPLE IRA

Timeliness: The assets you receive from the distributing IRA generally must be deposited into another IRA within 60 calendar days.

Required Minimum Distribution: Distributions that represent required minimum distributions paid to an IRA owner or beneficiary may not be rolled over.

Twelve‐Month Restriction: Effective for distributions taken on or after January 1, 2015, you are permitted to roll over only one distribution from an IRA (Traditional, Roth, or SIMPLE) in a 12-month period, regardless of the number of IRAs you own.

SIMPLE IRA Rollover Restriction: SIMPLE IRA assets may not be rolled over to a Traditional IRA within two years of the first contribution to your SIMPLE IRA.

DIRECT OR INDIRECT ROLLOVER FROM AN EMPLOYER‐SPONSORED RETIREMENT PLAN

Timeliness: If payable to you, the assets you receive from the distributing plan must be deposited into a Traditional IRA within 60 calendar days. Eligible Person: You are an eligible person only if you were or are a participant in an eligible plan, the surviving spouse beneficiary of a deceased participant, or the alternate payee (spouse or former spouse) identified in a qualified domestic relations order. A nonspouse ben-eficiary may roll over assets to an inherited Traditional IRA only as a direct rollover.

Eligible Plan: A distribution will not be eligible to be rolled over unless the distribution is made from an eligible employer‐sponsored retire-ment plan. A rollover contribution must be from one of the following eligible employer‐sponsored retirement plans: qualified retirement plan (Internal Revenue Code Section (IRC Sec.) 401(a) (e.g., 401(k), profit sharing, money purchase pension)), annuity plan (IRC Sec. 403(a)), tax‐sheltered annuity plan (IRC Sec. 403(b)), governmental deferred compensation plan (IRC Sec. 457(b)), or federal Thrift Savings Plan.

Ineligible Rollover Distributions. The following types of distributions are ineligible for rollover:

Required Minimum Distributions (RMDs) Hardship distributions Distributions that are part of a series of substantially equal periodic payments (made over single or joint life expectancy or for a specified period of 10 or more years) Returns of 401(k) elective deferrals because of the IRC Sec. 415 allocation limitations Returns of excess contributions and excess aggregate contributions from a 401(k) or 401(m) plan Returns of excess deferrals (i.e. amounts that exceed the deferral limit) Plan loan amounts that are treated as distributions because of a default or because the loan does not meet the IRC Sec. 72(p) requirements Dividends paid on employer securities as described in IRC Sec. 404(k) PS 58 costs (associated with life insurance coverage) Permissible withdrawals from eligible automatic contribution arrangements (generally within 90 days of the first automatic contribution) Designated Roth account contributions (these contributions may be rolled over only to a Roth IRA)

Form W-9(Rev. October 2018)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the

requester. Do not

send to the IRS.

Pri

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or

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e.

See

Sp

ec

ific

In

str

uc

tio

ns o

n p

age

3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

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); and2. 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. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup 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 for Part II, later.

Sign Here

Signature of

U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

Form W-9 (Rev. 10-2018) Page 2

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information.

Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

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;

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign

Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.3. The article number (or location) in the tax treaty that contains the

saving clause and its exceptions.4. The type and amount of income that qualifies for the exemption

from tax.5. Sufficient facts to justify the exemption from tax under the terms of

the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup WithholdingWhat is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the instructions for Part II for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships, earlier.

What is FATCA Reporting?The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.

Updating Your InformationYou must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

PenaltiesFailure to furnish TIN. If you fail to furnish your correct TIN to a

requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Form W-9 (Rev. 10-2018) Page 3

Criminal penalty for falsifying information. Willfully falsifying

certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C

corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.

IF the entity/person on line 1 is

a(n) . . .

THEN check the box for . . .

• Corporation Corporation

• Individual • Sole proprietorship, or • Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes.

Individual/sole proprietor or single-member LLC

• LLC treated as a partnership for U.S. federal tax purposes, • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes.

Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation)

• Partnership Partnership

• Trust/estate Trust/estate

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.

Exempt payee code.

• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

Form W-9 (Rev. 10-2018) Page 4

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt

for . . .

Interest and dividend payments All exempt payees except for 7

Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be reported and direct sales over $5,0001

Generally, exempt payees 1 through 52

Payments made in settlement of payment card or third party network transactions

Exempt payees 1 through 4

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup

withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations.

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 for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification

Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Part II. CertificationTo establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

Form W-9 (Rev. 10-2018) Page 5

1. Interest, dividend, and barter exchange accounts opened

before 1984 and broker accounts considered active during 1983.

You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts

opened after 1983 and broker accounts considered inactive during

1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of

secured property, cancellation of debt, qualified tuition program

payments (under section 529), ABLE accounts (under section 529A),

IRA, Coverdell ESA, Archer MSA or HSA contributions or

distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the RequesterFor this type of account: Give name and SSN of:

1. Individual The individual

2. Two or more individuals (joint account) other than an account maintained by an FFI

The actual owner of the account or, if combined funds, the first individual on

the account1

3. Two or more U.S. persons (joint account maintained by an FFI)

Each holder of the account

4. Custodial account of a minor (Uniform Gift to Minors Act)

The minor2

5. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

The grantor-trustee1

The actual owner1

6. Sole proprietorship or disregarded entity owned by an individual

The owner3

7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of:

8. Disregarded entity not owned by an individual

The owner

9. A valid trust, estate, or pension trust Legal entity4

10. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

11. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

12. Partnership or multi-member LLC The partnership

13. A broker or registered nominee The broker or nominee

For this type of account: Give name and EIN of:

14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))

The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.2 Circle the minor’s name and furnish the minor’s SSN.3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier.

*Note: The grantor also must provide a Form W-9 to trustee of trust.

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records From Identity TheftIdentity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Pub. 5027, Identity Theft Information for Taxpayers.

Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, 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 TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes.

Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

Form W-9 (Rev. 10-2018) Page 6

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.

Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.

Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.