Affidavit Of Unauthorized Use

Affidavit of unauthorized activity Except as may be provided below, I, , did not authorize any person other than myself to use my name or personal information to obtain access to or perform transactions in the above-referenced Shareholder account (the “Account”).

I did not authorize the following transactions in my Account: Date of Transaction Description of Transaction (purchase, sale, transfer, etc. ) Stock Symbol Number of Shares Dollar Amount Additional transaction details may be listed on a separate sheet and attached. This area reserved for office use.Page 2 of 4 Additional information Please check Yes or No to the below questions and provide any additional information needed: I have filed a police report: Yes If yes: No I have filed a police report with the law enforcement agency named below: Report Number: Police Department Address: Address Line 1 Address Line 2 Associative Officer Name: Badge Number: If charges are brought against the person(s) who has committed this fraud, I am willing to cooperate fully with law enforcement officials, including assisting in prosecution and authorizing the release of information.

I am aware that my computer has been infected with mallard (viruses, Trojan, etc). The following is a list of mallard I know my computer to be infected with: Additional information may be listed on a separate sheet and attached. Please check “l agree” or “l disagree” to the below: I did not receive any money, goods, or services nor did I benefit in any other way as a result of these unauthorized transactions.

I agree with the above I disagree with the above I did not knowingly share with any other person my Shareholder surname, logon ID, password, or other related confidential information.