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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 /> I STATE AG SETTLEMENT OFFER AMOUNT IN STATE AG SETTLEMENT <br /> Bank of America Corporation State AG Settlement <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 /> I <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 IT 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 /> 13 <br />