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MUST BE POSTMARKED <br />ON OR BEFORE <br />ALY28,2016 <br />II��I�IfN�I�MIIIn�IIIII�II�VIIIIB <br />CLAIM FORM <br />MUNICIPAL DERIVATIVES SETTLEMENTS <br />FOR OFFICIAL USE ONLY <br />01 <br />Page 1 of 4 <br />To be considered, your Claim. must be submitted online (at www.MunicipalDerivativesSettlement com), OR mail it by July 28, 2016. <br />See Part 6 for General Instructions. <br />i <br />PART I: CLAIMANT IDENTIFICATION - Please type or print. Use blue or black ink only. <br />i <br />Business As <br />Name of Representative submitting the Claim Form <br />Number and Street or P.O. Box <br />Telephone Number (Day) <br />I <br />i <br />Email Address <br />TVI <br />Title/Capacity <br />State Zip Code <br />Telephone Number (Evening) <br />1 —7 <br />Account Number <br />i iuiii.iiiii niu iiiii iui ini i mini iiin iii uii 111111111111111111111111111111 s <br />