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i <br />{�IIIIIIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII Illll IIII IIII _ 000�Zo4�z <br />0000510660� <br />PART 3: PREVIOUS DISTRIBUTIONS FROM THE STATE AG SETTLEMENTS <br />If you received an Offer from one or more of the State AG Settlements listed below relating to Municipal Derivatives Transactions, list the <br />total amount of the State AG Offer in the appropriate box, and state whether the Offer was accepted. If you do not, your claim may be <br />rejected. You DO NO TI need to include documentation; however, if you have documentation establishing the following, please attach it. <br />The Settlement Administrator may request documentation during auditing. <br />YES OR N0: WAS OFFER ACCEPTED <br />! STATE AG SETTLEMENT OFFER AMOUNT IN QTeT9: er_ QCTri Cumm <br />Bank of America Corporation <br />State AG Settlement <br />- - -- <br />.......�....v..IIL-L-mL.nI <br />GE Funding Capital Market Services, Inc. State AG Settlement <br />JPMorgan Chase & Co.; State AG Settlement <br />Wachovia Bank N.A. State AG Settlement <br />UBS AG State AG Settlement <br />PART 4: SIGN AND DATE YOUR CLAIM FORM <br />Enter EIN <br />• Please enter the Employer Identification Number ("EIN"). <br />Employer Identification Number <br />• If you are exempt <br />}'from backup withholding, enter your current EIN above and write "exempt" on the following line: <br />I <br />UNDER THE PENALI Y OF PERJURY, I (WE) CERTIFY THAT. <br />1. The number show on this form is the entity's/entities' current EIN; and <br />2. We declare that we are a Class Member as defined in the Notices, that we are not one of the "Released Parties" as defined below, <br />and that we believe we are eligible to receive a distribution from the Net Allocation Funds under the terms and conditions of the <br />Distribution Plan. <br />3. We have included information about all of our transactions in Municipal Derivatives which occurred between January 1, 1992, and <br />August 18, 2011. <br />4. We understand and intend that the signature below regarding certain information for the Internal Revenue Service concerning backup <br />withholding also serves as the signature verifying the information and representation in this Claim Form. <br />5. We have not assigned or transferred or intended to assign or transfer, voluntarily or involuntarily, any matter released by filing a claim here. <br />6. 6. We certify that we are NOT subject to backup withholding under the provisions of Section 3406(a)(1)(C) of the Internal Revenue <br />Code because: (a) we are exempt from backup withholding; or (b) we have not been notified by the Internal Revenue Service that we <br />are subject to badkup withholding as a result of a failure to report all interest or dividends; or (c) the Internal Revenue Service has <br />notified us that we are no longer subject to backup withholding. <br />NOTE. If you have been notified by the Internal Revenue Service that you are subject to backup withholding, please strike out the <br />language that you are not subject to backup withholding in the certification above. The Internal Revenue Service does not require your <br />consent to any provision other than the certification required to avoid backup withholding. <br />Page 3 of 4 77 <br />