| REDEMPTION CALCULATOR | 
|---|
        | Enter your data separately for each tax lot (i.e. purchase date): | 
		| 1. Name of stock paying a deemed redemption | or enter your own data:
 
 | 
		        | 2. Date of original purchase (mm/dd/yyyy) (tax lot) |  | 
        | 3. Date of redemption payment (mm/dd/yyyy) |  | 
		| 4. Number of shares owned for this tax lot | (no commas) | 
		| 5. Cost basis before redemption payment (total, not per share) | $  (no commas) | 
		| 6. Amount of redemption payment per share | $  (no commas) | 
	
		| 7. Market value per share prior to redemption | $ (no commas) | 
		| 8. Percent of share redeemed | $ (no commas) | 
			
		| 9. Reverse split factor for share | $ (no commas) | 
			
		| 10. Tax treatment of redemption where 1 is market value method and 2 is reverse split ratio method | $ (no commas) | 
			
		
		| Comments |  | 
        | Tax information statement |  | 
	
        | 11. Account or Owner Name (optional) |  | 
        |  |  |