Part IV. Signature

I make the following agreements and declarations:

1. I agree to comply with the conditions and agreements set forth in Rev. Proc. 2009–20 and this document.

2. Under penalties of perjury, I declare that the information provided in Parts I-III of this document is, to the best of my knowledge and belief, true, correct and complete.

Your signature here Date signed: Your spouse’s signature here Date signed:

Corporate Name Corporate Officer’s signature Title Date signed

Entity Name

S-corporation, Partnership, Limited Liability Company, Trust Entity Officer’s signature Date signed

Signature of executor Date signed

April 6, 2009 754 2009–14 I.R.B.