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IhIIIflIIIV�IIIIIIIIU�N��l�llllllll ,_ We declare under penalty of perjury under the laws of the United States of America that all of the foregoing information supplied on this Proof of Claim is true and correct. Executed this day of , 20 in (City) (State/Country) Signature of person signing on behalf of Entity/Borrower (Type or print name of person signing on behalf of Entity/Borrower) 1 Capacity of person signing on behalf of Claimant PART 5: MAIL YOUR CLAIM FORM Complete and sign the enclosed Claim Form and mail it by July 28, 2016 to: Municipal Derivatives Settlement c/o Rust Consulting, Inc. P.O. Box 2500 Faribault, MN 55021-9500 For information on submitting your claim electronically, go to www.MunicipalDerivativesSetuement.com. PART 6: GENERAL L INSTRUCTIONS NOTICE REGARDING ELECTRONIC FILES: Certain claimants with large numbers of transactions may request, or may be requested, to submit information regarding their transactions in electronic files. All Claimants MUST submit a manually signed paper Claim Form whether or not they also submit electronic copies. If you wish to submit your claim electronically, you must call the Settlement Administrator toll-free at 1-877-310-0512, send an e-mail to info@MunicipalDertvativesSettlement com, or visit www.MunicipalDe6vativesSettlement.com to obtain the required file layout. • You should be aware that it will take a significant amount of time to process fully all of the Claim Forms and to administer the Settlements' This work will be completed as promptly as time permits, given the need to investigate and tabulate each Claim Form. Please be patient. • Please notify the.Settlement Administrator of any, change of address. CLAIMANT IDENTIFICATION • If the entitylyou represent purchased or otherwise acquired Municipal Derivatives, the entity is the borrower as well as the record purchaser. However, if the entity you represent purchased the Municipal Derivative transactions that were registered in the name of a third parry, such as a nominee or brokerage firm, the third party is the purchaser. • Use Part 1 hof this form to identify the purchaser of record (the "borrower"), if different from the beneficial purchaser of Municipal Derivative transactions which form the basis of this claim. I NOTE: A single!Claim Form should be submitted per legal entity and should include all transactions made by that entity, no matter how many separate accounts that entity has. DEFINITIONS Capitalized terms not defined in this Claim Form have the same meaning as defined in the following Settlement Agreements: UBS AG Settlement Agreement, Societe Generale, S.A. Settlement Agreement, Natixis Funding Corp., f/kla IXIS Funding Corp., and before that, f/kla CDC Funding Corp. Settlement Agreement, Piper Jaffray & Co. Settlement Agreement, National Westminster Bank plc Settlement Agreement, and George K. Baum & Company Settlement Agreement. (The Settlement Agreements, in their entirety, are available at www MunicipalDerivativesSettlement.com.) Page 4 of 78 803