| Print or Type | Name(see shown on your income tax return) |
| Business name/disregarded entity name, if different from above |
| Check appropriate box for federal tax classification(required):☐ Individual/sole proprietor ☐ C Corporation ☐ S Corporation ☐ Partnership ☐ Trust/estate☐ Limited liability company. Enter the tax classification(C=C corporation,S=S corporation,P=partnership)▶Other ▶ | ☐ Exempt payee |
| Address(number, street,and apt.or suite no.) |
| City,State,and ZIP code |
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). For other entities, it is your employee identification number (EIN).
## Part II Certification
Under penalties of perjury, I certify that:
Under penalties of perjury, I certify that.
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (!RS) 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 in the instructions}.
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.
## 2. □ Non-U.S. Person
I am not a U.S. person (including a U.S. resident alien). I am submitting the applicable Form W-8 with this form to certify my foreign status and, if applicable, claim tax treaty benefits.
For example: Client is not a U.S. person (including a U.S. resident alien). Client agrees to provide DBS1 with this application the applicable Internal Revenue Service (IRS) Form W-8 to certify the client’s foreign status. W-8 forms and instructions are available on the IRS website at www.irs.gov.
13-AWM-0196
012145.032813
CONFIDENTIAL – PURSUANT TO FED. R. CRIM. P. 6(e)
USAO 001984
DB-SDNY-0001024
EFTA00169621
BY SIGNING BELOW CLIENT ACKNOWLEDGES THAT: (1) CLIENT HAS RECEIVED, READ AND AGREES TO THE TERMS AND CONDITIONS OF THIS ACCOUNT AGREEMENT, INCLUDING THE APPENDIX WHICH CONTAINS IMPORTANT INFORMATION; AND (2) THE INFORMATION CONTAINED IN THIS ACCOUNT APPLICATION IS ACCURATE.
CLIENT ACKNOWLEDGES THAT THIS ACCOUNT AGREEMENT CONTAINS A PRE-DISPUTE ARBITRATION CLAUSE AT SECTION III, PAGE 5, AND CLIENT AGREES TO ITS TERMS (ALL ACCOUNT AGREEMENT SIGNATORIES MUST INITIAL).
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE CLIENT'S CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING, AND, IF APPLICABLE, THE CERTIFICATION REQUIRED TO ESTABLISH CLIENT'S STATUS AS A NON-U.S. PERSON AND ORTAIN A REDUCED RATE OF WITHHOLDING.
Important Information for ERISA employee benefit plan clients: U.S. Department of Labor regulations require DBSI to disclose to a responsible plan fiduciary certain information in connection with the services that DBSI provides to a plan, to assist the fiduciary in evaluating the reasonableness of DBSI’s services and related compensation. The disclosure is available online, at http://www.pwm.db.com/americas/en/erisa_disclosure_pcs.html. By signing below, you acknowledge that you are a fiduciary responsible for the procurement of DBSI’s services to the plan, you have read the disclosure and you understand the disclosure.
Individual or joint account (IF THIS IS A JOINT ACCOUNT, ALL ACCOUNT OWNERS MUST SIGN):
CONFIRMATION OF TAX AND COMPLIANCE RESPONSIBILITIES
Client acknowledges having sole responsibility to fulfill any tax obligations and any other regulatory reporting duties applicable in any relevant jurisdictions that may arise in connection with assets, income or transactions in Client's account(s) and business relationship with DBSI.
CHECK A BOX BELOW ONLY IF CLIENTS DO NOT WANT JOINT TENANTS WITH RIGHTS OF SURVIVORSHIP OR TENANTS BY THE ENTIRETIES.
CLIENTS SPECIFY INSTEAD:
Tenants in common; or
Community Property (for married couples in certain states; each spouse retains 50% interest in the community property upon death of the first spouse)
Signature ___ Date ___
Print Name ___ SSN/EIN ___
Print Name ___ SSN/EIN ___