T STATE 'NONE CONNECTICUT RESIDENCE ADDRESS IR. BOX NOT ACCEPTABLE) ADDRESS: 28 Belden Amnia CITY. Norwalk STATE: CT ZIP: 06850 ADDRESS 242 Frenldln Stint MG OTC Danbury STATE: CT ZP. 06910 SIGNATURE ACCEPTING NIP°, PAGE 1 OF 2 - • . Rev. 1/11/2011 06/06/2014 FRI 12:53 ETX/RX NO 566S] g