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Disclaimer: <br />This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice, <br />and are furnished without representation or warranty. While this form/cover sheet is believed to satisfy <br />minimum legal requirements as of its revision date, compliance with applicable law, as the same may be <br />amended from time to time, remains the responsibility of the user of this form/cover sheet. Questions should <br />be addressed to the user's legal, business or tax advisor(s). <br />AUTHORITY Page 3 of 3 Rev. 12/01/2011 <br />