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Get B 2100A (Form 2100A) (12/15)

The information provided in this notice is true and correct to the best of my knowledge and belief. By: Transferee/Transferee s Agent Date: Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. 152 & 3571.

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