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1IIII 1101 2 II VIII 11111113 V6 5 6 7 III VIII VIIIVIIIVIII8 9IIIIIIII <br />* <br />The Internal Revenue Service does not require your consent to any provision other than the certification required to avoid backup <br />withholding. <br />I (We) declare under penalty of perjury under the laws of the United States of America that all of the foregoing information supplied on <br />this Proof of Claim by the undersigned is true and correct. <br />Executed this day of , 20 in <br />(City) <br />Signature of Claimant <br />(State/Country) <br />Type or print name of Claimant <br />Signature of Joint Claimant <br />Type or print name of Joint Claimant <br />Signature of person signing on behalf of Claimant <br />Type or print name of person signing on behalf of Claimant <br />Capacity of person signing on behalf of Claimant <br />Reminder Checklist: <br />1. Please sign the above release and declaration. <br />2. If this Proof of Claim and Release form is being made on behalf of Joint Claimants, then both must sign. <br />3. DO NOT USE HIGHLIGHTER ON THE PROOF OF CLAIM FORM. <br />4. Keep a copy of your Proof of Claim form and all documentation submitted for your records. <br />5. If you move after submitting this Proof of Claim, please send your new address to the Claims Administrator at the address below: <br />U.S. Dollar LIBOR Settlement <br />P.O. Box 2602 <br />Faribault, MN 55021-9602 <br />Email: info@BarclaysLiborSettlement.com <br />Page 6 of 6 <br />P173 <br />