A. NATURE OF THE PAYMENT
Check the applicable box.
1. ☐ Complete Termination of Interest
2. ☐ Substantially Disproportionate Redemption
3. ☐ Not Essentially Equivalent to a Dividend
4. ☐ Distribution Taxable Under Section 301(c) of the Code
B. CERTIFICATION
Under penalties of perjury, I declare that I have examined the information on this form, including the information I provided in Section A above, and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that I am the beneficial owner (or am authorized to sign on behalf of the beneficial owner) of the Payment.
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C. ATTRIBUTION RULES
For purposes of determining whether the Payment qualifies as a distribution taxable under Section 301(c) of the Code or as proceeds from a sale or exchange under Section 302(a) of the Code, you must determine your percentage ownership in the Company under U.S. federal income tax rules both before and after the Payment. In addition to stock that you own directly, you are generally considered for this purpose to own any stock owned (directly or indirectly) by or for:
1.
Your spouse, children (including adopted children), grandchildren, and parents;
2.
A partnership or estate of which you are a partner or beneficiary, in proportion to your interest in the partnership or estate;
3.
A trust (or portion thereof) for which you are considered the owner under the “grantor trust” rules;
4.
A trust, in proportion to your actuarial interest in the trust (but not if it is an employees’ trust described in Section 401(a) of the Code that is exempt from tax under Section 501(a));
5.
A corporation of which you own (directly or indirectly) 50 percent or more in value of the corporation’s stock, in that proportion which the value of the stock you own bears to the value of all stock in the corporation;
6.
If you are a partnership or estate, any stock owned (directly or indirectly) by or for a partner or beneficiary;
7.
If you are a trust (other than an employees’ trust described in Section 401(a) of the Code that is exempt from tax under Section 501(a)), any stock owned (directly or indirectly) by or for a beneficiary, unless the beneficiary’s interest is a remote contingent interest. A contingent interest of a beneficiary in a trust is considered remote if, under the maximum exercise of discretion by the trustee in favor of such beneficiary, the value of such interest, computed actuarially, is 5 percent or less of the value of the trust property;
8.
If you are a grantor trust, stock owned (directly or indirectly) by or for the grantor; and
9.
If you are a corporation, any stock owned (directly or indirectly) by or for a person who owns (directly or indirectly) 50 percent or more of the value of your stock.