Super Duper Test Claim Form Holder | Strategic Claims Services

Phone

This field is for validation purposes and should be left unchanged.

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CLAIMANT INFORMATION

The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at info@strategicclaims.net. Complete names of all persons and entities must be provided.

Beneficial Owner's Name

Co-Beneficial Owner’s Name

Entity Name

(if the Beneficial Owner is not an individual)

Representative or Custodian Name

(if different from Beneficial Owner(s) listed above)

Address

Address 1 (street name and number) Address 2 (apartment, unit or box number) City State / Province / Region ZIP / Postal Code Country

Last four digits of Social Security Number or Taxpayer Identification Number

Telephone Number (home)

Telephone Number (work)

Email

Enter Email Confirm Email

Account Number (where securities were traded)1

Claimant Account Type

(check appropriate box)

Individual (includes joint owner accounts)

Corporation

IRA/401K

Pension Plan

Estate

Trust

Other

1. If the account number is unknown, you may leave blank. If filing for multiple accounts, file a separate Claim Form for each account.

SCHEDULE OF TRANSACTIONS IN COMMON STOCK

1. BEGINNING HOLDINGS

State the total number of shares of common stock held at the opening of trading on January 11, 2023. (Must be documented.) [If none, enter “0.”]

2. PURCHASES

Separately list each and every purchase of common stock from after the opening of trading on January 11, 2023 through and including the close of trading on March 20, 2024. (Must be documented.)

Date of Purchase/ Acquisition (List Chronologically)(Month/Day/Year)

Number of Shares Purchased

Purchase Price Per Share

Total Purchase Price (excluding taxes, commissions, and fees)

3. SALES

Separately list each and every sale/disposition (including free deliveries) of common stock from after the opening of trading on January 11, 2023 through and including the close of trading on March 20, 2024. (Must be documented.)

Date of Sale (List Chronologically)(Month/Day/Year)

Number of Shares Sold

Sale Price per Share

Total Sale Price (excluding taxes, commissions, and fees)

4. ENDING HOLDINGS

State the total number of shares of common stock held at the close of trading on March 20, 2024. (Must be documented.) [If none, enter “0.”]

BALANCE CHECK

Below is a summary of the transactions you entered. Your Beginning Holdings plus Purchases minus Sales and Ending Holdings should equal zero. Please correct any errors below to ensure that all transactions are accounted for.

BEGINNING HOLDINGS

TOTAL PURCHASES

TOTAL SALES

ENDING HOLDINGS

Balance Confirmation

Outstanding Shares

This field shows the number of shares that are outstanding based on what you have entered in the Beginning Holdings, Purchases, Sales, and Ending Holdings fields. When all shares are accounted for, the balance in this field will be zero.

Balance Check Error*

Documentation

You are required to attach proof as part of the online filing process. Please attach your files below.

Upload Files

If you have a large number of files, please consider uploading a ZIP file.

Drop files here or

Accepted file types: pdf, tiff, zip, xlsx, docx, Max. file size: 32 MB.

Confirmation

I have reviewed all of my answers to the fields on this form and confirm that everything is accurate to the best of my abilities.

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Signature of Claimant

Signature of Joint Claimant

Signature of person signing on behalf of claimant

(Capacity of person(s) signing, e.g. beneficial purchaser(s), executor, administrator, trustee, etc.)

Date*

Unique ID

Super Duper Test Claim Form Holder Online Claim Form

CLAIMANT INFORMATION

SCHEDULE OF TRANSACTIONS IN COMMON STOCK

BALANCE CHECK

Balance Confirmation

Documentation