Common use of Acknowledgement and Signature Clause in Contracts

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and will not hold Computershare Trust Company, N.A. and its agents are not liable for any adverse consequences that may result. I understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am responsible for ensuring I am eligible to authorize this transfer/conversion and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my directions. I have been advised to seek competent legal and tax advice, and have not been provided any such advice from the IRA Trustee/Custodian. Signature Date

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA Xxxx XXX will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and will not hold Computershare Trust Company, N.A. and its agents are not liable for any adverse consequences that may result. I understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am responsible for ensuring I am eligible to authorize this transfer/conversion and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my directions. I have been advised to seek competent legal and tax advice, and have not been provided any such advice from the IRA Trustee/Custodian. Signature Date

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and (Note: This Application will not hold be processed unless signed below by the Depositor and Responsible Individual By signing this Xxxxxxxxx ESA Application, you certify that the information you have provided is true, correct, and complete, and the Custodian Computershare Trust Company, N.A. n.a. may rely on what you have provided. In addition, you have read and its agents are not liable for any adverse consequences that may resultreceived copies of the Xxxxxxxxx ESA Application, IRS Form 5305-EA, Disclosure Statement and applicable fee schedules. I You agree to be bound to their terms and conditions. You understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am you are responsible for ensuring I am eligible to authorize this transfer/conversion the Xxxxxxxxx ESA transactions, and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to you will indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my your directions. I If you have indicated any amounts as “carryback” contributions, you understand the contributions will be credited for the prior tax year. You understand that if the deposit establishing the Xxxxxxxxx ESA contains rollover dollars, you elect to irrevocably designate this deposit as a rollover contribution. You have been advised to seek competent legal and tax advice, advice and have not been provided any such advice from the IRA Custodian. You also agree that you have received and read the brochure describing the Computershare Investment Plan with Altria Group, Inc Common Stock under this Plan. In addition, as you certify that: (1) all contributions that you make to the CESA meet the requirements of the Internal Revenue Code governing such contributions; (2) you understand and accept any applicable fees that are a part of this agreement and authorize deduction of any fees from the CESA if you do not make direct payment; (3) you will promptly provide instructions to the Custodian necessary to enable the Custodian to carry out its duties under this agreement. Computershare Trust Company, N.A., hereby accepts appointment as Custodian of this CESA Trustee/Custodian: For transfer of shares Please send a physical certificate and transfer form. Signature DateSend the above- specified cash and/or securities to Computershare at P.O. Box 2175, Milwaukee, WI, 00000-0000. You may also contact a Client Service representative at 0.000.000.0000 for DTC Instructions The IRA Program c/o Computershare Trust Company, N.A. 000 X. Xxxxxx Xxxxxx Milwaukee, WI 53212-3948 The IRA Program c/o Computershare Trust Company, N.A. P.O. Box 2175 Milwaukee, WI 53201-2175 Please print all items except the signatures. If you have questions, call toll free from 8a.m. to 8 p.m. Eastern Time, Monday through Friday. Mail your completed form to the address above. If stock certificates are enclosed, please send by registered mail. Please consult the Xxxxxxxxx Education Savings Account (“CESA”) Custodial Agreement and Disclosure Statement for additional information about moving CESA assets into your CESA Investment Plan, and read the Company’s Investment Plan prospectus for information regarding the IRA Program. 1. Designated Beneficiary Information (Distributing CESA) 2. Responsible Individual Information 3. Designated Beneficiary Information (Receiving CESA) Note: Complete this section only if the ESA assets are coming from an ESA with a different Designated Beneficiary than the Designated Beneficiary identified in Part 1 above.

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and (Note: This Application will not hold be processed unless signed below by the Depositor and Responsible Individual By signing this Xxxxxxxxx ESA Application, you certify that the information you have provided is true, correct, and complete, and the Custodian Computershare Trust Company, N.A. n.a. may rely on what you have provided. In addition, you have read and its agents are not liable for any adverse consequences that may resultreceived copies of the Xxxxxxxxx ESA Application, IRS Form 5305-EA, Disclosure Statement and applicable fee schedules. I You agree to be bound to their terms and conditions. You understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am you are responsible for ensuring I am eligible to authorize this transfer/conversion the Xxxxxxxxx ESA transactions, and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to you will indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my your directions. I If you have indicated any amounts as “carryback” contributions, you understand the contributions will be credited for the prior tax year. You understand that if the deposit establishing the Xxxxxxxxx ESA contains rollover dollars, you elect to irrevocably designate this deposit as a rollover contribution. You have been advised to seek competent legal and tax advice, advice and have not been provided any such advice from the IRA Custodian. You also agree that you have received and read the brochure describing the Computershare Investment Plan with Xxxxxx Xxxxxx International Inc. Common Stock under this Plan. In addition, as you certify that: (1) all contributions that you make to the CESA meet the requirements of the Internal Revenue Code governing such contributions; (2) you understand and accept any applicable fees that are a part of this agreement and authorize deduction of any fees from the CESA if you do not make direct payment; (3) you will promptly provide instructions to the Custodian necessary to enable the Custodian to carry out its duties under this agreement. Computershare Trust Company, N.A., hereby accepts appointment as Custodian of this CESA Trustee/Custodian: For transfer of shares Please send a physical certificate and transfer form. Signature DateSend the above- specified cash and/or securities to Computershare at P.O. Box 2175, Milwaukee, WI, 00000-0000. You may also contact a Client Service representative at 0.000.000.0000 for DTC Instructions Computershare Trust Company, X.X. Xxxxxxxxx Education Savings Account Enrollment Form Xxxxxx Xxxxxx International Inc The IRA Program c/o Computershare Trust Company, N.A. 000 X. Xxxxxx Xxxxxx Milwaukee, WI 53212-3948 The IRA Program c/o Computershare Trust Company, N.A. P.O. Box 2175 Milwaukee, WI 53201-2175 Please print all items except the signatures. If you have questions, call toll free from 8a.m. to 8 p.m. Eastern Time, Monday through Friday. Mail your completed form to the address above. If stock certificates are enclosed, please send by registered mail. Please consult the Xxxxxxxxx Education Savings Account (“CESA”) Custodial Agreement and Disclosure Statement for additional information about moving CESA assets into your CESA Investment Plan, and read the Company’s Investment Plan prospectus for information regarding the IRA Program. 1. Designated Beneficiary Information (Distributing CESA) 2. Responsible Individual Information 3. Designated Beneficiary Information (Receiving CESA) Note: Complete this section only if the ESA assets are coming from an ESA with a different Designated Beneficiary than the Designated Beneficiary identified in Part 1 above.

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and (Note: This Application will not hold be processed unless signed below by the Depositor and Responsible Individual By signing this Xxxxxxxxx ESA Application, you certify that the information you have provided is true, correct, and complete, and the Custodian Computershare Trust Company, N.A. n.a. may rely on what you have provided. In addition, you have read and its agents are not liable for any adverse consequences that may resultreceived copies of the Xxxxxxxxx ESA Application, IRS Form 5305-EA, Disclosure Statement and applicable fee schedules. I You agree to be bound to their terms and conditions. You understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am you are responsible for ensuring I am eligible to authorize this transfer/conversion the Xxxxxxxxx ESA transactions, and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to you will indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my your directions. I If you have indicated any amounts as “carryback” contributions, you understand the contributions will be credited for the prior tax year. You understand that if the deposit establishing the Xxxxxxxxx ESA contains rollover dollars, you elect to irrevocably designate this deposit as a rollover contribution. You have been advised to seek competent legal and tax advice, advice and have not been provided any such advice from the IRA Custodian. You also agree that you have received and read the brochure describing the Computershare Investment Plan with Ford Motor Company Common Stock under this Plan. In addition, as you certify that: (1) all contributions that you make to the CESA meet the requirements of the Internal Revenue Code governing such contributions; (2) you understand and accept any applicable fees that are a part of this agreement and authorize deduction of any fees from the CESA if you do not make direct payment; (3) you will promptly provide instructions to the Custodian necessary to enable the Custodian to carry out its duties under this agreement. Computershare Trust Company, N.A., hereby accepts appointment as Custodian of this CESA Trustee/Custodian: For transfer of shares Please send a physical certificate and transfer form. Signature DateSend the above- specified cash and/or securities to Computershare at P.O. Box 2175, Milwaukee, WI, 00000-0000. You may also contact a Client Service representative at 0.000.000.0000 for DTC Instructions The IRA Program c/o Computershare Trust Company, N.A. 000 X. Xxxxxx Xxxxxx Milwaukee, WI 53212-3948 The IRA Program c/o Computershare Trust Company, N.A. P.O. Box 2175 Milwaukee, WI 53201-2175 Please print all items except the signatures. If you have questions, call toll free from 8a.m. to 8 p.m. Eastern Time, Monday through Friday. Mail your completed form to the address above. If stock certificates are enclosed, please send by registered mail. Please consult the Xxxxxxxxx Education Savings Account (“CESA”) Custodial Agreement and Disclosure Statement for additional information about moving CESA assets into your CESA Investment Plan, and read the Company’s Investment Plan prospectus for information regarding the IRA Program. 1. Designated Beneficiary Information (Distributing CESA) 2. Responsible Individual Information 3. Designated Beneficiary Information (Receiving CESA) Note: Complete this section only if the ESA assets are coming from an ESA with a different Designated Beneficiary than the Designated Beneficiary identified in Part 1 above.

Acknowledgement and Signature. I understand that conversions from a Traditional IRA to a Roth IRA will be treated as a distribution and may be considered ordinary income for tax purposes. I have been advised to consult a tax professional and assume full responsibility for this conversion transaction and (Note: This Application will not hold be processed unless signed below by the Depositor and Responsible Individual By signing this Xxxxxxxxx ESA Application, you certify that the information you have provided is true, correct, and complete, and the Custodian Computershare Trust Company, N.A. n.a. may rely on what you have provided. In addition, you have read and its agents are not liable for any adverse consequences that may resultreceived copies of the Xxxxxxxxx ESA Application, IRS Form 5305-EA, Disclosure Statement and applicable fee schedules. I You agree to be bound to their terms and conditions. You understand that the resigning custodian will remit any income tax which has been withheld to the Internal Revenue Service on my behalf and I have made my election directly with them. I also understand that if I recharacterize, amounts previously withheld may only be refunded by the Internal Revenue Service. Amounts withheld may be subject to a 10% early withdrawal penalty in addition to income tax. By signing this IRA Transfer/Conversion Request Form, I certify that the information I have provided is true and correct. I authorize the current IRA Trustee/Custodian to transfer/convert the IRA assets as instructed above. I understand that I am you are responsible for ensuring I am eligible to authorize this transfer/conversion the Xxxxxxxxx ESA transactions, and I assume all responsibilities for any consequences that arise as a result of my actions. I agree to you will indemnify and hold the IRA Trustee/Custodian harmless from any consequences related to executing my your directions. I If you have indicated any amounts as “carryback” contributions, you understand the contributions will be credited for the prior tax year. You understand that if the deposit establishing the Xxxxxxxxx ESA contains rollover dollars, you elect to irrevocably designate this deposit as a rollover contribution. You have been advised to seek competent legal and tax advice, advice and have not been provided any such advice from the IRA Custodian. You also agree that you have received and read the brochure describing the Computershare Investment Plan with Wal-Mart Stores, Inc Common Stock under this Plan. In addition, as you certify that: (1) all contributions that you make to the CESA meet the requirements of the Internal Revenue Code governing such contributions; (2) you understand and accept any applicable fees that are a part of this agreement and authorize deduction of any fees from the CESA if you do not make direct payment; (3) you will promptly provide instructions to the Custodian necessary to enable the Custodian to carry out its duties under this agreement. Computershare Trust Company, N.A., hereby accepts appointment as Custodian of this CESA Trustee/Custodian: For transfer of shares Please send a physical certificate and transfer form. Signature DateSend the above- specified cash and/or securities to Computershare at P.O. Box 2175, Milwaukee, WI, 00000-0000. You may also contact a Client Service representative at 0.000.000.0000 for DTC Instructions The IRA Program c/o Computershare Trust Company, N.A. 000 X. Xxxxxx Xxxxxx Milwaukee, WI 53212-3948 The IRA Program c/o Computershare Trust Company, N.A. P.O. Box 2175 Milwaukee, WI 53201-2175 Please print all items except the signatures. If you have questions, call toll free from 8a.m. to 8 p.m. Eastern Time, Monday through Friday. Mail your completed form to the address above. If stock certificates are enclosed, please send by registered mail. Please consult the Xxxxxxxxx Education Savings Account (“CESA”) Custodial Agreement and Disclosure Statement for additional information about moving CESA assets into your CESA Investment Plan, and read the Company’s Investment Plan prospectus for information regarding the IRA Program. 1. Designated Beneficiary Information (Distributing CESA) 2. Responsible Individual Information 3. Designated Beneficiary Information (Receiving CESA) Note: Complete this section only if the ESA assets are coming from an ESA with a different Designated Beneficiary than the Designated Beneficiary identified in Part 1 above.