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Form Ta-1 - Uniform Form For Registration As A Transfer Agent And For Amendment To Registration Pursuant To Section 17a Of The Securities Exchange Act Of 1934 Page 2

OFFICIAL USE

Applicant Name: _________________________________________________

FORM TA-1

Page 2

Date: __________________________________________________________

6. Has registrant, as a named transfer agent, engaged, or will it engage, a service company

Yes

to perform any transfer agent functions?

If “yes,” provide the name(s) and address(es) of all service companies engaged, or that will be

engaged, by the registrant to perform its transfer agent functions:

_____________________________________________________________________________________________

Name:

_____________________________________________________________________________________________

Address: (Number and Street)

(City)

(State)

(Zip Code)

_____________________________________________________________________________________________

Name:

_____________________________________________________________________________________________

Address: (Number and Street)

(City)

(State)

(Zip Code)

_____________________________________________________________________________________________

7. Has registrant been engaged, or will it be engaged, as a service company by a named transfer

Yes

agent to perform transfer agent functions?

If “yes,” provide the name(s) and FINS number(s) of the named transfer agent(s) for which the registrant

has been engaged, or will be engaged, as a service company to perform transfer agent functions:

Delete

__________________________________________________________________________________

Name:

FINS Number:

__________________________________________________________________________________

Name:

FINS Number:

__________________________________________________________________________________

Name:

FINS Number:

__________________________________________________________________________________

Name:

FINS Number:

__________________________________________________________________________________

Name:

FINS Number:

__________________________________________________________________________________

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT

CONSTITUTE FEDERAL CRIMINAL VIOLATIONS.

See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)

EXECUTION: The registrant submitting this form, and as required, the SEC supplement and Schedules A-D,

And the executing official hereby represent that all the information contained herein is true, correct and complete.

Manual signature of Official responsible for form:

Title:

Name of Official responsible for form:

Date executed (Month/Day/Year):

(First name, Middle name, Last name)

Form Ta-1 - Uniform Form For Registration As A Transfer Agent And For Amendment To Registration Pursuant To Section 17a Of The Securities Exchange Act Of 1934 Page 2

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