EFTA00317154.pdf

Agreements & Signatures Taxpayer identification. The following certification must be completed by the proposed Owner or the new Owner if changing. For joint Owners, the certification must be completed by the Owner who will be the primary owner& tax reporting and withholding purposes. By my signature, I, the Proposed/New Owner, certify under penalties of perjury, that: a. The number shown in Section B or Section C is my correct Taxpayer Identification Number 0 Yes 0 No b. I am NOT subject to backup withholding: 0 Yes 0 No c. I am a U.S. person (including a U.S. resident alien): 0 Yes 0 No The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. Owner (At time of application or Current Owner after issue.) At time of Application. I, the undersigned, have read the Application including all supplements and all statements and answers, and affirm that these statements and answers are true, complete and correctly recorded to the best of my knowledge and belief. To the best of my knowledge and belief, all statements made in the Part 1 are true, complete and correctly recorded. I hereby adopt all statements made in the Application and agree to be bound by them. Atter issue. I, the undersigned, consent to transfer of ownership. Signature of Owner: Printed name: Date: Title (Required when applicable): 0 Sole Officer Printed name of Corporation/Partnership/Trust (If applicable): City/State where application is being signed (Time of application only): Signature of Additional Owner (If applicable): Printed name: Date: Title (Required when applicable): Printed name of CorporationPartnership/Trust (If applicable): — New Owner (Only complete if changing ownership.) I, the undersigned. agree the information provided on this form is true. complete and correctly recorded to the best of my knowledge and belief. Signature of New Owner Printed name: Date: Title (Required when applicable): 0 Sole Officer Printed name of Corporation/Partnership/Trust Of applicable): Signature of Additional New Owner (If applicable): Printed name: Date: Title (Required when applicable): Printed name of CorporationlPartnership/Trust (If applicable): Witness Signature Section A witness is a disinterested party (anyone other than the Owner. Insured or Beneficiary). Signature of Witness: Printed name: Date: F5248-US Owner Designation Form — 0413 EFTA00317154