Structured Products Agreement and Approval Form Please Complete Alt Sections Hviritni fitment Nam: G -023i,011 S :$1/4.7 \--‘6 '9_)J hpcIpti_ LL c_. Account Type Poi:m.OW amill Pm ;cm IK I snne,nb isale:t &Poway Cu. ptomain Oat:, rsir.ci:d NOTE: IRA and ERISA accounts are prohibited from purchasing Structured Products. Account and Owner Information: Provide requested information for wricli beneticial account owner ("Client"). If momMannth: owner e%ists. the Structured Products Agreement and Approval Suppiontentary Form to this Agreeinerit may be required. four: Mune m r es:. Middle. Last Name M Imienclua Tre.tce m ElitCleall G s-c6- .).) 6i oeccf-f) l- co occtww,v.ez R2 , --11-)Ot/NoIS Pion? US V‘Pz‘t. tsi,A.1.106 31.p T4-5- 2c)-11-3- 1,4-int41 Sul its Xlirtheai,; - 1.11.410O/YY let C rnt)So,,P, "S\ 3CriCC. Nit° /17 53 sG6F hwat, hickest Ncip\IC-, trre••If POSioon 11.)A k1O iNCoviCIK-s Own/e2- lid:ill:(S) O, D.:, :0640 oilierI n netouni OVir1:1(:, auil,ancd iaplace maws fa i he accome ?Mil-- ; DeateN) kwol)(6 Client(S) Financial Information Approximate Aggregate Annual Income of Account Owner(s) from All Sources Less than $50,000 550,000 - S99,999 .9100,000 - 5249.999 5250,000 - Se99,999 5500.000 - S999.999 51,000,000 - S2.499,999 52.500.000 - $4,999.999 [500.000 and °very wr:i rime SPN, 0MR oi I017.0330I7 ISMS Sources of Income (Approximate) Salary/Bonus 94 In ierest/Divid:mds IGO % Other (specify): Illumbm 01 oviwittlinti RIAsIV.APII00.• 340-in -252,5 Approt:intaie Net Worth Less than $50,000 550.000 - S99.999 S100,000 - 5249.999 6250.000 - $499,999 $500,000 - S999.999 $1,000,000 - 52.499.999 52 50n 9 999 Appro.:intake Liquid Net Worth Excluding Principal Residence Less than 550.000 550.000 - 599.999 5100.000 - 5249.999 5250.000 - 9499.999 S500.000 - 5999.999 S1.000.000 - S2.499.999 S2,500.000 - S4.999.999 S5.000,000 and eve' CONFIDENTIAL — PURSUANT TO FED. R. CRIM. P. 6(e) DB-S