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MUST BE POSTMARKED <br />ON OR BEFORE <br />DECEMBER 21, 2017 <br />1* 0 1111811111111 2 11111111111111134 5 6 7 8 1111111111111111111111119* <br />01 <br />In re LIBOR -Based Financial Instruments Antitrust Lit. <br />11 -MD -2262 (NRB) <br />PROOF OF CLAIM AND RELEASE <br />Use Blue or Black Ink Only <br />PART I: CLAIMANT IDENTIFICATION - Please type or print. <br />A. Complete the following Section. <br />Page 1 of 6 <br />Entity Name/Beneficial Owner <br />Name of Representative submitting the Claim Form <br />Title/Capacity <br />B. Account/Mailing Information: <br />Number and Street or P.O. Box <br />City <br />Foreign Province and Postal Code <br />Telephone Number (Day) <br />Email Address <br />Taxpayer Identification No. <br />State <br />Foreign Country <br />Zip Code <br />Telephone Number (Evening) <br />Account Number <br />I 11111111111111111111111141 <br />11111111 111111111111 <br />1 11111111 11 1111111111111 11 1111 <br />P168 <br />