First Name *

Middle Name

Last Name *

Are you Representing an Entity*
YesNo

Address *

Country *

State *

City *

Zip Code *

Phone Number *

Email *

Are you a current or former employee of the company?*
YesNo

I, , of , certify that:

• 1. I have reviewed the complaint and authorized its filing and/or adopted its allegations.

• 2. I did not purchase , the security that is the subject of this action at the direction of plaintiff’s counsel or in order to participate in any private action arising under this title.

• 3. I am willing to serve as a representative party on behalf of a class and will testify at deposition and trial, if necessary.

• 4. My transactions in , during the class period set forth in the Complaint are as follows:

(Please upload broker statements or trade confirmations showing the dates, prices and amounts of all of your individual trades in Please feel free to redact your account numbers from your uploaded documents. The Law Offices of Howard G. Smith is committed to protecting the privacy of confidential information. The Law Offices of Howard G. Smith will only use your documents to recover money for you.)

5. I have not served as a representative party on behalf of a class under this title during the last three years except as stated:

6. I will not accept any payment for serving as a representative party, except to receive my pro rata share of any recovery or as ordered or approved by the court including the award to a representative plaintiff of reasonable costs and expenses (including lost wages) directly relating to the representation of the class.

I declare under penalty of perjury that the foregoing statements are true and correct.