In a ~wee Mist al* m11***Ill ••14 41; ttrightr stlett.lit tkrains tE la %no( Eman. Pitasi (11 Ming. 0 Jr • • Or • ed. • • eat/ Sens, Pan C ••••• . . . . . • • . . , • • ..., IN WrittESS WaRlite0P. di* certifase hat beta slabiscribei*t . day or pkboe44113:64.110B

inimis Exemption set forth in item (4) of Part B above. If this item is applicable to the Investor, please answer the applicable items set forth in Pan C below. (12) None of the above items in this Part A is applicable with respect to the Investor. If the investor did not initial item (4) or ite

ent, are a US person. If you are not a US person, please complete this Pan A and continue to Part C a»dreturn signed, completed copies of Pan A and Pan C to your DB representative. If you are a US person, please complete this Part A and continue to Pan B and return signed, completed copies of Port A a

N CERTIFICATION Please indicate below whether you (anent, are a.US person. If you are not .0 VS person, please complete this Part A and continue to Pan C ant return signed, completed copies of Pan A and Pan C to your DB representative If you are a US person, please complete this Part A and continue t

nical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet

inical reasoning or evidence for exemption: DOE Code 3 I cestift that the physical condition of this child Lt nth that immenitatiomNat indicated in Pan C above is medically caltraindicated. Physician or Clinic Name: (flint or stamp) Address: D44 610, 1196. dada= la (4Omo (SIM Maher 574.11O:MX1106)

cal reasoning or evidence for exemption: DOE Code 3 I certify that he physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Address. Physician Signature. DN 680, &NS repbces earlier ed

nical reasoning or evidence for exemption. DOE Code 3 1 cent that the physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 680, 8/2000, obsoktm tallitt