EFTA00237760.pdf

UBS Financial Services Inc. UBS Account Number Check here if this document applies to multiple accounts. Letter of Authorization for Duplicate Recipient of Tax Records This letter authorizes UBS Financial Services Inc. to send a copy of your tax form for the below accounts) to the following interested party(ies). Such authorization will continue for ten years unless terminated by IRS Financial Services Inc or until you notify UBS Financial Services Inc. in writing of your decision to terminate the mating of your tax reports to the parties below Be advised that the service only pertains to your form 1099, I099R or 1099O. If you are eligible to receive a different tax report, this will not be sent to the below parties Also be aware that if you are a beneficiary on an account or a participant of a qualified plan, you are not eligible to enroll the account to send duplicate lax information to a third party. Interested Party Information ?may select up to four) INTERESTED PARTY Robert Kuchner First Name Middle Name Last Name Address Line I Address Line 2 New York NY 10017 City State Zip 4 Im Address Email Phone Ghislaine Maxwell Account Owner First Name Last Name Account Owner Signature Date 0159495149 i AC-CPT ;Rev 10/11) O2011 EMS Financial Services Inc. Al rights reserved. Member SIPC Pa^e1/, CONFIDENTIAL UBSTERRAMAR00002181 EFTA00237760