Ear beginning and ending (m m / d d / y y y y) Shareholder s name . (m m / d d / y y y y) Shareholder s identifying number Address City Corporation s FEIN State ZIP code State ZIP code California corporation number Corporation s name Address City . A Current year allocation percentage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B Shareholder s number of shares: . . . . .

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