a UBS UBS Financial Services Inc. Account Number ( Check here if this document applies to multiple accounts Letter of Authorization for Duplicate Recipient of Tax Records This letter authorizes UBS Financial Services Inc. to send a Copy of your tax form for the below account(s) to the following interested party(ies) Such authorization will continue for ten years unless terminated by UBS Financial Services Inc. or until you notify UBS Financial Services Inc. in writing of your decision to terminate the Mailing of your tax reports to the parties below Be advised that the service only pertains to your form 1099, 1099R or 10990. If you are eligible to receive a different tax report, this will not be sent to the below parties Also be aware that if you are a beneficiary on an account or a participant of a qualified plan, you are not eligible to enroll the account to send duplicate tax information to a third party Interested Party Information (may select up to four) INTERESTED PARTY Alan __ Blecher First Name Middle Name Last Name Address Line 1 ~ ~ Address Line 2 ~~ City State Zip : Email Address Phone Ghislaine _ Maxwell _ _ _ \ _ a Account Owner First Name Last Name Account Owner Signature Date 0159495149 ; AC-DPT (Rev. 10/11) ©2011 UBS Financial Services Inc. All rights reserved. Member SIPC Page 1/1 CONFIDENTIAL UBSTERRAMARO0002180 EFTA00237759