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In Part A, select the reason for distribution by marking the appropriate box. If you choose 'Other', provide a brief description of your reason.
Proceed to Part B, where you will need to complete a separate section for each distributee. Enter the name, Social Security Number or Employer Identification Number, and telephone number of the first distributee.
For each distributee, describe the securities and/or related payments by filling in the title of security, issue date, face amount, identifying number, and registration details.
In Part C, sign and certify that all information is accurate. Ensure that signatures are completed in front of a certifying officer who will also sign and stamp the form.
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