EFTA00237169.pdf

Investor Application Form (continued) G Certification Regarding initial Public Equay Offerings: tiiiit Rule 5130 "Rastected Persons" tt re card may elect t M to wrest in new Mae, net, it yOur indredual account 4 ei9tfe for such transactions. °tease MIS the appropriate daternart the ;in:8e~ has urtheed those stars/nu bekw react> appy to 4 a. 4 the Undesired n a ..Nioton, partrersr-r 'tin “ , .,.. ,-.tryy. *tech apply to am pers Sawn; a Ilseelittiel Inter= n Ow Unefethred The Investor is any of she folksesiney ;a: Asi AMARA reinter fink a teer brake dealer An officer. director. genera) panntr, associated peson or ~year &afire/IA member firma ~Coveted Woke Des. K) An are O. a Cased Broke Oslo if the agent is engaged r the Tralin2eini bank") or Straiten busmen (<4 An ~ha jonrot Venter of a person specified minor :O ads, te) AMC* or pew. actng in a fotspurt capacey to a Coveted Erse Defier, inducing attorneys. accountants and reseal torailtsre s. CC A pins So het te authority to buy or sea waste. ta a bilk, saw and its institubcti, ~rare cumpeny, investment company Ywesmsted Ss or Coheyore investrnex Arrant (g. An Mediate f anlayeAtreits of a person spoke O2,i ow if, ettode ararecess from a ortredes to such porton %Wend Support, ffi: Aston trsted reowed so be hoed Se Schedule A or Schedule C to form 90 as sang 1014 or mete diseased Broker Cray n; Aetna, Interdict required to telisachn Wreak» 8 a Schield"! ce Form ID Whole ownweteb Wane.: IS Been:anon lined Og. (s) Amur that cons chectty a *erect 10% or more of • Ault teparIng company Sad is required to be lad) m Schedule A cd fare 8O mle mewl b a Covered Broke Dear, other than a cubit company that n Mad on a natcesai secedes «change, tie) Assort that own tray a onteireale 25% or more cheat& reporting company that newton totted in (t) rebore other than a pubk compare rut is Wad or a naNsnal sed..-thes aching,. An friarae tart* Menbe tK a MICA trsterf an 7t tfrough 2) aide vino nooses Can Of pranks to such penal Mattel Supeart. "ele: An xount ~ a comae on. pirmotArp, Unread Sabah company. tnni ar other enotenn **gel ON of the Penom reftied to in re; theough arose has a 8enalciai hi!~ rany pers In Ca) through OW. a '5130 Restricted Person' , the ~Of n hen. r! the abercr For EntrIne. catty. If you inituried any of ;tem. (a) through (m) else, you may stia be eligidir to participate in new ~ea" if you warily one of the *sensations limed under 'Ns Issues Esamptions- et the back of the Subscription Astnirerrient. tf so. pies specify the exemption number (1 trough 10) here (exemption 1(b) n not evistebie), NOTE: Ezeinwhons we not applicable for individual rettarnent accounts, individual or Joint accounts. USIA* or UTMA accounts, which are treated es natural persons for this purpose Private and Confides hai CONFIDENTIAL UBSTERRAMAR00001524 EFTA00237169  Investor Application Form (continued) G. Certification Regarding Initial Public Equity Offerings (cont'd): Mt -11AL Rule S131 "Covered Persons" Please wwl below if applicable .s :t mesa, is a COtTOrabOn. parser ho. Ce Ong!MP!. much aC00, Ia any Pence hartli3 Sentient Interest n the ".ty.r.: pit Mann. a any ;tenon having a Reneficiel Interest et the netts, a (4 an newt.* Ohm: a *lector Naga:4r Company a a Cowed Scn-Pubie Company. a ;a) a tenon recereng Maltese' Support by an eeecubve Offtter or Water of a Potdc Company a a COvited 1 / 0ftPolifk COWAN tan/ peons xi (e. a Zit. a '5131 Covered Pests') 2 fit If you initsilikl statement tt)ebore. you Must NOW Oath tekviet Pubic Company Odra C mere htn-Pudic Company: (31 It sou inhaled slateenenlitlarenO, Oen what Cm fOlklenng ontpf such apperable Able Covey" a Covered Non-Pct e Company tal ty curets* a dent mama? Itrestmera Banking Seven provided Dyer:14Ra nemesis a hat ate tontpenSettOn to a FPAA member to Ithentneri Ranfung Satyrs el PIO past 11momM, . (b; expects to retain a tinge nst‘mtv. fa nvestrnent Bank-% Sem:es men the art 3 thonIn. :r hat pruned no an express of ended obigaton owes( r evinkety 'Navy* :es met love o!Ircen a rectal. to wen \cc:. enema. fa the oracemaree ol fat.oe natu-nent Ransil Sevres if you 'abated any of Fran (a) through (c) above, you may still be toga& to partiopete in 'new issues' it you satisfy one of the exemptions fisted under "New Issues Exemptions' et the bubo. the Suburb:4*o Aq..enant It so. pleas* specify the exemption number here lexempton 1(0 is not a tellettett It the Investor has rep esented that he. she or it is not a llesunted Penon" or • 'Coveted Parson. the investor tureen represents that he. she of it understands that Otis certificate expires attar one year and ones promptly to notify the Fund ShOuld the account become • 'Itestinted Arson' of 'Cowed Person'. N. Government Entity Status V, If* kneSIOr a 601.1•Pliter. I 0 Vas /No d Path-west& s ears as agent, tepresentame a natant* to one a rope irdeStal. d any d sucr investors a Gmettvnent trete CI 'Ms /No (at: if the mover to question .* as ' Yee, please akar/ the navies <A any such Ireton Private and Centidennal CONFIDENTIAL UBSTERRAMAR00001525 EFTA00237170  Investor Application Form (continued) I. NFA Bylaw 1101 Certification (Please Initial as appropriate. Individual. MA and Foundation Marston: p:(purl.. And aetarn. teat 4 4 an exandue. WA ca a Wandamin and that it *not reseed to bra oteroset atdo wooed f sautes tunas re/FA': or 10 De rettlered Mtr. the Commodity Futsses hada"; Comninsion 'CFTC any capacity Chase Carrara Y' 0 into, I nester Adrionredpentent) OR NI ads fealty Investorc The Invests:a tOr..1 dat 144410 1 4 4 0:141410tbri poet. 141' operates thereat reoresen3 are wartants stilled required to be rtamoa :! gum n• In be yerrlevr4 me err in any ta :0 (Please note. Mule not always the case generally. certarn mums investment vehides suds as mole member limited habristy companies and (erten !trotted pannerships comprised of family members. among others. should maid this section and below if appluablis) Ole la...titer n a tun] a reeve Ovetament entity and mitten nen 1;4 /Wee Owe coepete the tolloswit; the finned o e tangy mesteent whickwilMit hobos...nes include reit %OMt thicken. in awl, sydre444,- 5 cousins• or tee Senor is a lush dim and has tied • notice sot the C*1C under NO-Action Ins. 12-37 Ihr fresh, reties upon an ternoton two. recistrates under CF IC R* 4 13 and has Ned a notice dieing ern werripbon ends the NIA The IneStal teas soon an adawn tram the Seaton ct the term 'commode, pool operator mkt Olt Ilsbe 4 5 and has tempt° . clans; Mrs wermeon midi Pe KA TN fleesl0f is a 00nr mittens, plan. a contrtubtry *trod bereht plan a powwowed dan, an employee weds benefit plan. et a church plan maned said trot Employes Setement Sono Sio.say Act cat 1974 the Investor •exaes „Der anomer tampon or o oms is not steed to muster with the CRC epees }fleiKate cetow ter ageagerSe exenveen upon which Mr instor rein a indica the Mtn upon which Ow Mosta run deserrnmed teat most can v an esentritor a not rewrote OR Entities that an MA Members and/er those requited to register with the OTC Ire tnwitta tor. it the :vette e n a cenvrodity pool. the opet slot thereof, represents end warrants Mat it rs a mentor or the NIA and is 10741.01.0 semi the CFTC Please exte4W bets the capacity in witch the Mess to the operates Meteor, 6 recySeeredlosermackey pool operator. tommoody trading) admix turn conwassion merchant. introduon0 pro w. or ?Ad %sir ilanWS With respect to any..suctt gen Kq vieach la employee may Masse 40,414:Ute no portal of an eleleyet f Centrazur, nn it forrennei e 'neon 's leactmt10 kruch pritvsr"ccr12. Pi nate and Confidential CONFIDENTIAL UBSTERRAMAR00001526 EFTA00237171  Investor Application Form (continued) J. Instestcar Acknowledgement The oncerogod *hood roe sr tai nines ! as 16 &Net. ,1 ?Se Slenter, e - 10, Gnosis c' S income tatabon Ca The Undersigned represent that he, she Of ‘t is a 'Undid States person' (as such term is defined in the Code) for purposes of U.S. federal income taaaron and has peovidad to U.S a valid and duly completed Form W.9. or successor form thereto, signed undies penalties of perjury by such pre teen tot ins( Undersigned. The Undersigned certifies under pension of perjury that (A) its U.S. texpayec egad to mein identification number. as it appean in the inventor Application form m this Subscription Booklet. is true and correct and VII it it NOT subject to backup withholding because either, (I) it es exempt from backup withfrolding. (2) it has not been nabbed by the U.S Internal Revenue Service ("IRS") that it is subject to backup enthhokling as a result of a failure to report cal interest 04 dividends. or (I) the IRS has notified it that it is no longer subject to backup withholding. The Unckesnpied reel nobty the fund within IS days if any of the above certifications ate no longer valid Upon 0104.14et by the fund or UBSFA. the Undersigned snarl promptly furnish to the Fund valid and duty completed loon W-9. 04 successor town thereto, signed under penalties or perjury by such undersigned The ..:nadigned he. rtvew•C and coofintad at of the ,rlorabon in the mentor App.:con and Lbeir-fnl• that a6 ot ft* Intormabos that is legated to be pcowied by the Underbred in des Investor AP:skater is Snit /tang and complete an as fait IS ice The URRetskned refonard'S that he. Steal has recessed, carefulty teed arc wd be bound by the Agreements, nciuding the pcedkoisde arbibisbal dents Wrneh appears as the SubsCription Agreement and the fund Adreerrent and agrees that wand below cortstedes the erecution and receipt of the Agreements The 00/Rdloral retsillersh that he. thecae hin received a copy of the k14 / .00, 404Sum, has mod 0 and uraktstanch it, and the trade erect rt at We of the fund's Seed wchmons on Vanderatility and aittictrawar he. the a .t understands that an wrest:rent eV lye Fund neWes coeds of interest, induckg that the liacement Agent and its Oblates we wen payments horn the Irrestors. to Fund ansito their *hates bated odor the aggregate scant at rapt* conelbutcm to thefts-4 IN The Undersigned Condom that the raiment objwwe and nik drags 49pliCat to •A• ,fronertt e‘ this Fund are reedetwery. *raida adpreciaton" and "wenn. This obscure and risk profile 6 appgratie ant, to thnerresunent and may *Ate trorn the everstment goals and tlik to trice for the meta portfolio and** brokerage account at *tech thsirneweent is NS 0) The thxlempriec undreltedi Mit en derestrnent in ow Fund may impact tit 1.500cycyletES future Soddy (She long or short.bemI ard teresertn dial the Undersigned s ryes/nerd goats ace sonata.il with rte tent hone of the investment (g) the Undersigned hereby autrya,zes the debt of hinds foe the Centat Com:buten. plod any 1006able Kacement FM. and any Jackal* amount reduced to satisfy a tat obtgabon of the Fund the 14/ kderugned urgeSUndS that SAW may in AS Sale and abialde dnerenOn acted as Sur CM.. COintration an amount ins than .'$t.! (0b100../b041 appiled tOr here the Undersgried certeas that the United States is hi. he iSt its country of r.ndenCe dr rem gal hue OK* CA gandli lit Undenrgnad Canna( Mika thin ceettaton. Memo tab to your Financial " ant itra nrOdtra Aelmor Skit weedier yCy may tent in the laid elbe 3 3, The Undersigned arerovdedan that a Placement fee of 2% of the Capital ConthbutOn WA be swat charged the tuthelteseriel refits thigh a Itraloge account HOW" I t In ' ted pia arts:', bran may Of MUM, circumstances the Plaramery fee may be waved by the Penn; Agent ten Placement Fee et 10 .'t in addlOs m, and wit no. redact Pr unclersgrecry Capt.. CordrOubcro d the Placement Fee is reduCed by arement teener ire Pavement Agent and the Undersigned Wien the reCksted ISartnent Fee to were the Vnities•thed hat. /greed wit te reflected on the LAS trade coneemeton The teritrygned contann that the Placement fee has been discussed with hrytiettits Ariancial /Wawa and an/ aCkiLOrlai qa$40ref we be addressed if redivided No PUCennln! Fee et charged a eh, orrestenern is Made IMO-dna:AS eslitoOrli ccencrem Private and Confidential CONFIDENTIAL UBSTERRAMAR00001527 EFTA00237172  Investor Application Form (continued) 1. Investor Atka's,*Wyman( (wordy. tic; FOR GRANTOR tg,iS'S 0t v ft Plt L.flotagried it a Wargeti Undnitgsd atimaivggiges sat ay and a grown of Pt twit as I.:Spencers knit. Societal income tat purposes !please nose ;cantor trusts vas non-U S persons as pranton may not Invest in thts Fune0 K. Investor Signatures: awe sga Debit Reese rote that swag 0SP* torabtats you, vongure to the Investor Appecatsr form. the SubacAption Agreement and he Furs ere n accnidance vein art ifertIS Aanr.li MW 5.9‘611. • . we.", 174r* _gahiS .“ Nene Joint tAcrtWe MAKE SURE YOU NAVE COMPUTED AU. APPLICABLE SECTIONS OF THIS INVESTOR APPUCATION FORM. Pnvate and Czethdential CONFIDENTIAL UBSTERRAMAR00001528 EFTA00237173  ,,, W-9 ee. Deemer 4 / 4 Request for Taxpayer Gen Fonn to Ras requester. Do not Identification Number and Certification sand to the IRS. t r . llear,... Sew* l 74ene as Woe on rca 'ozone lax eat bet s ear« an toe ...b. 00 not aber• Me ane Dirt Chastain. Maxwell 2 Banco bribrberebleCee eats Nat t caret tan Wow S", Specific Instruction* On Page 2 3 Clog acoroonaar Ca rce as lei Claberon enera at ~goo g et % ear ca b • Seam 3:00««Ph only b 0 latuabere reatece or «own weals not recta Ire O C 0:400Obb O S ettOotsto O rtilltn O Tnagint• reran on owe 3I raga at« Ilt Print or type O 'stoic)«bey <Dan, freer VW la. camas IC•C carearaltra 2e4 ccowalaak anaalneno04 17 lobe te«. coat Or *on Mott Fea Ø LIO bet le berara cl0 ree OW* G.C. bib we aPPrOla Øe to• let an tar Snow Ø CATCA tarp bp taa easaeste or me wagementee bow «Oats IMO O Ober Saltairacttnile P easebetemeavatywaRkr i. 5 ~a PIPSTO•r_ One. WO Ocil Or sue ro ) Anoteteds norm and acicheaa tooter* • Ceo, rat ma 2IP Ø New York. NY 10065 7 L. a_onor renbana • let ~leg P rt I «payer Identification Number (TIN) Ea• r >an c tat aocropnate tea Tne 7,N PoW0O0 'Mt non) We name goon al Anm t to miod ions "tura ~Do bactup earanoka G Fa anal/trios. t4 o balerarly y00 ICON Ilebalty nurnbtr CSS•41 albatatr. $e a • 185~1ten sae ~reg. Or ctsregarcko ert.ty. tat tea Part I ethers co page 3 Fa Ober catte3 ma you' ~Oyer girebbton Nat» (OM lr 30u dana nett a tunable. 5« aber ro pot a flu cn Dow 3. a Noe. I! the accost mat nila. om nSent 5« tta -nao~ to. nee 1 and re chat on page 4 Ica asteitos iderceacatio• muter 1 nes aatObl number 10 ens I - P.ut II Certification tinter ~Des at perm). I whey that. 1. The number onna on trar tarn rt ray Carib taapayer Ceolltiebste Ara alb vrabnO 10' a nrbtOt to le Oto•O to "'re MO 2 lam nat Marla 10 loaCb4) atalthoicang tease wiarnanueca Iran beam" ~No -Ono. a te ) nave na men fl ied Dy the nano; %so Since ORS) teatime abaci to teacup witra~ as a nail ed. tattre to report at tnteneet of ctroancla of lc} the IRS Ma AMMO rn• , lagh am no Ø SoO0C1 to «Cat* lebborboli 3 s am a U S °tun a Ober U S «Mr lOnneCI belOw), and 4 Yet FAT CA codes) errand on pas 7OrT fat any; axecaong ~lam ila•MOC tot FAT CA reccrong o co•rset Certification ~auctions. you ',Vat cross out OCT 2 stow t you owe Der neat« by Ma ;VS OW you see eery rasa to back,* enflue n9 Diar ne tas« to noon at wow and ~Mends on vOue tat «urn Foe se estata tramachons. ern 2 ooh not appy. For mortgage niprest Pad_ =later a ~Mint at «CO« 110301y. canCatabon d coal. COrltra0~1110 in erfreeleai ranee &nano:~ Cale. artd re,etazt, patter« Ober fl an apeos ro Cbgergt you we not storel to espe.mcaten.mr)ou map rabble ybe ObeCt 71*. Set WS ..1t.c tort or peas 3 a Vlli rienetalatt. Owe neral Instructions • Form tale Obit magete Inlerea ‘096-• ala« ben Seel 109S-7 (We VOCSCrt ue lo no Internal Mer« Cob cnnowv• nowt • Fenn nO9PC ~at det? Nam. dovotownonta ontoowtco WWI *war ••••• "KW; Fro 2t-e Wcit or ege«~NY 24 *94,111b0C, ~lea be «ea bast soot " go. te9 • rel" VSO-4 ~On re WS LI« Font aala3 ore it act as • U S «non brat a rated Si la Purpose of Form PrO4O4 ?Olt Corer Tel Ar cloal a erns (faro W-9 moan .mo s tee« b be r somata" Nu Op ne .ara. Form We to we taster ma • 71.• you ogle be bbrect arten tan.»'PS rna: «tat St Camel laborer ØaØ mureir cre b perms W01~ Soo ~el a boast strtroone, on sco • me, us sou, focal~fly alter ‘SS•41. ago tagrotr clearbSce e• 'WM S4-.S Win yet, rangy C'Irt adoptcn bola ebiltiatean auras tn."16 •fi ntknor Cott^ OW to Tel act SO pert • Cover la we ere a•wao )))) a ••fints• carrecaton~Oa «tat to modal an Sons mown ra annee oat b to tot es~ pa a Slav eat McOleatioe w eionteron barn •Operyle or ranee Wert most. OS Se is ~OS So ate; 2 COON Ws WuNMI wAyat to ~me wit~ 7.* • Foie bradea feat elelf5OrMg 3 Clan age« lee terclepahlabeflatein • u S erg am, r • Form INOCIN~Ina ~kip tios tens Soba or n..la AnS ~ea byu N also~ thee ot • LLSS amok parr ad» Won O. try «Onset moat tom a U S. trade cc a* is steel to 11.4 • for!, IfØarleC~maws awns. on era ce row ~awe WITt~ ISO On WOWS WY* CA ^CS* 00~ an• • %on 'o996 SSW a nrotwl *OW Sal« XIS ~ten a trilMa0414 tnt 4 Zarb raM FATCA matt Sad onI« bear cob oCKS42 /NO you at vann act trot tie FATCA ~cans 4 WY« See VOW es FATCAI saws as • goon' ICOIS ecoracla ace 'es waft Obboont cage 2W Saw ~alas • Fain 1C994‹ ,merchart coo ins Mae Dery reams r'ate'n' Cat No t3731)( Ccen W-9 (Pm 12-2•014) CONFIDENTIAL UBSTERRAMAR00001529 EFTA00237174