Department of the Treasury
Internal Revenue Service
Report of Organizational Actions
Affecting Basis of Securities
See separate instructions.
OMB No. 1545-0123
Part I Reporting Issuer
1 Issuer's name 2 Issuer's employer identification number (EIN)
3 Name of contact for additional information 4 Telephone No. of contact 5 Email address of contact
6 Number and street (or P.O. box if mail is not delivered to street address) of contact 7
City, town, or post office, state, and ZIP code of contact
8 Date of action 9 Classification and description
10 CUSIP number 11 Serial number(s) 12 Ticker symbol 13 Account number(s)
Part II Organizational Action Attach additional statements if needed. See back of form for additional questions.
14 Describe the organizational action and, if applicable, the date of the action or the date against which shareholders' ownership is measured for
15 Describe the quantitative effect of the organizational action on the basis of the security in the hands of a U.S. taxpayer as an adjustment per
share or as a percentage of old basis
16 Describe the calculation of the change in basis and the data that supports the calculation, such as the market values of securities and the
For Paperwork Reduction Act Notice, see the separate Instructions.
Cat. No. 37752P