PLAINS ALL AMERICAN PIPELINE LP
EX-10.1
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<DESCRIPTION>EX-10.1
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<p align="right" style="margin:0in 0in .0001pt;text-align:right;text-autospace:none;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">EXHIBIT 10.1</font></b></p>

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<p style="margin:0in 0in .0001pt;text-autospace:none;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">GLA/HNP
Form</font></b></p>

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<p align="center" style="margin:0in 0in .0001pt;text-align:center;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&#171;GrantDate&#187;</font></p>

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<p align="center" style="margin:0in 0in .0001pt;text-align:center;text-autospace:none;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman"><font style="font-size:10.0pt;">&#171;FirstName&#187;</font>&#171;LastName&#187;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&#171;Address1&#187;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman"><font style="font-size:10.0pt;">&#171;City&#187;</font>,
&#171;State&#187; &#171;PostalCode&#187;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 1.0in;text-autospace:none;text-indent:-.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Re:</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Grant of Restricted
Units</p>

<p style="margin:0in 0in .0001pt 1.0in;text-autospace:none;text-indent:-.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Dear &#171;FirstName&#187;:</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">I am pleased to inform you that you have been granted &#171;Units&#187; Phantom Units as of the above date pursuant
to the Company&#146;s 2005 Long-Term Incentive Plan (the &#147;Plan&#148;).&#160; In addition, in tandem with each Phantom Unit
you have been granted a distribution equivalent right (a &#147;DER&#148;). The terms and
conditions of this grant are as set forth below.</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">1.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Subject to
the further provisions of this Agreement, your Phantom Units shall vest (become
payable in the form of one Common Unit of Plains All American Pipeline, L.P.
for each Phantom Unit) as follows: (i) 30% shall vest upon the later to occur
of the May 2007 Distribution Date and the date on which the Partnership pays a
quarterly dividend of $0.65 per unit, (ii) 30% shall vest upon the later to
occur of the May 2009 Distribution Date and the date on which the Partnership
pays a quarterly distribution of $0.70 per unit, and (iii) 40% shall vest upon
the later to occur of the May 2010 Distribution Date and the date on which the
Partnership pays a quarterly distribution of $0.75 per unit.&#160; Any Phantom Units that remain unvested, and
all associated DERs (whether or not vested), as of the May 2011 Distribution
Date (after giving effect to the distribution on such date) shall be forfeited.</p>

<p style="margin:0in 0in .0001pt .5in;text-autospace:none;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">2.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Subject to
the further provisions of this Agreement, your DERs shall vest (become payable
in cash) as follows: (i) 30% shall vest upon and effective with the earlier to
occur of the May 2007 Distribution Date and the date on which the Partnership
pays a quarterly dividend of $0.65 per unit, (ii) 15% shall vest upon and
effective with the earlier to occur of the May 2008 Distribution Date and the
date on which the Partnership pays a quarterly distribution of $0.675 per unit,
(iii) 15% shall vest upon and effective with the earlier to occur of the May
2009 Distribution Date and the date on which the Partnership pays a quarterly
distribution of $0.70 per unit, (iv) 20% shall vest upon and effective with the
earlier to occur of the May 2010 Distribution Date and the date on which the
Partnership pays a quarterly distribution of $.725 per unit, and (iv) 20% shall
vest upon and effective with the earlier to occur of the May 2010 Distribution
Date and the date on which the Partnership pays a quarterly distribution of
$0.75 per unit.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">3.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Your DERs
shall not accrue payments prior to vesting.</p>

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<p align="center" style="margin:0in 0in .0001pt;text-align:center;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">4.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Any
distribution level required for vesting under paragraphs 1 or 2 above shall be
proportionately reduced or increased for any split or reverse split,
respectively, of the Units, or any event or transaction having similar effect.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">5.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Upon
vesting of any Phantom Units, an equivalent number of DERs will expire.&#160; Any such DERs that are vested prior to, or
that would vest as of, the Distribution Date on which the Phantom Units vest,
shall be payable on such Distribution Date prior to their expiration.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">6.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>In the
event of the termination of your employment with the Company and its Affiliates
(other than in connection with a Change in Status or by reason of your death or
&#147;disability,&#148; as defined in paragraph 7 below), all of your then outstanding
DERs (regardless of vesting) and Phantom Units shall automatically be forfeited
as of the date of termination; <u>provided, however</u>, that if the Company or
its Affiliates terminate your employment other than a Termination for Cause,
any unvested Phantom Units that have satisfied all vesting criteria as of the
date of termination but for the passage of time shall be deemed nonforfeitable
on the date of termination, and shall vest on the next following Distribution
Date; <u>provided, further</u>, that any DERs associated with the unvested,
nonforfeitable Phantom Units described in the preceding proviso shall not be
forfeited on the date of termination, but shall be payable and shall expire in
accordance with paragraph 5 above.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">7.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>In the
event of termination of your employment with the Company and its Affiliates by
reason of your death or your &#147;disability&#148; (a physical or mental infirmity that
impairs your ability substantially to perform your duties for a period of
eighteen months or that the Company otherwise determines constitutes a &#147;disability&#148;),
all of your then outstanding Phantom Units and tandem DERs shall be deemed 100%
nonforfeitable on such date, and such Phantom Units shall vest in accordance
with paragraph 1 and paragraph 2 above.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">8.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>In the
event of a Change of Status, all of your then outstanding Phantom Units and tandem
DERs shall be deemed 100% nonforfeitable on such date, and such Phantom Units
shall vest in full upon the next Distribution Date.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="font-size:10.0pt;margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">9.</font><font size="1" style="font-size:3.0pt;">&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font>Upon
payment pursuant to a DER, you agree that the Company may withhold any taxes
due from your compensation as required by law.&#160;
Upon vesting of a Phantom Unit, you agree that the Company may withhold
any taxes due from your compensation as required by law, which (in the sole
discretion of the Company) may include withholding a number of Common Units
otherwise payable to you.</p>

<p style="margin:0in 0in .0001pt 60.0pt;text-autospace:none;text-indent:-24.0pt;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">As used herein, the phrase &#147;Distribution Date&#148;
means the date, in any given month and year, on which the Partnership pays a
quarterly distribution.</font></p>

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<p align="center" style="margin:0in 0in .0001pt;text-align:center;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The phrase &#147;Change in Status&#148; means the occurrence, within three months
prior to or one year following a Change of Control, of any of the following
circumstances:&#160; (A) any termination by
the Company of your employment other than a Termination for Cause, (B) without
your consent, any removal of you from, or any failure to re-elect you to, the
positions held by you&#160; (or substantially
equivalent positions) immediately prior to the change that may constitute a
Change in Status, or (C) any reduction in your base salary or (D) any material
reduction in your fringe benefits.</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The phrase &#147;Change of Control&#148; means, and shall be deemed to have
occurred upon the occurrence of, one or more of the following events:&#160; (i) any sale, lease, exchange or other
transfer (in one transaction or a series of related transactions) of all or
substantially all of the assets of the Partnership or the Company to any Person
and/or its Affiliates, other than to the Partnership or the Company, including
any employee benefit plan thereof; (ii) the consolidation, reorganization,
merger or any other similar transaction involving (a) a Person other than the
Partnership or the Company and (b) the Partnership, the Company or both, (iii)
any person, including any partnership, limited partnership, syndicate or other
group deemed a &#147;person&#148; for purposes of Section&nbsp;13(d) or 14(d) of the
Securities Exchange Act of 1934, as amended, becoming the beneficial owner,
directly or indirectly, of 50% or more of the membership interest in the
Company, (iv) the persons who own membership interests in the Company on the
date hereof cease to beneficially own, directly or indirectly, more than 50% of
the membership interest in the Company, or (v) the Company ceasing to be the
general partner of the general partner of the Partnership.</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The phrase &#147;Termination for Cause&#148; shall mean severance of your
employment with the Company or its Affiliates based on your (i) failure to
perform your job function in accordance with standards described to you in
writing, or (ii) violation of the Company&#146;s Code of Business Conduct (unless
waived in accordance with the terms thereof), in each case, with the specific
failure or violation described to you in writing.</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The &#147;Company&#148; refers to Plains All American GP LLC.&#160; The &#147;Partnership&#148; refers to Plains All
American Pipeline, L.P.</font></p>

<p style="margin:0in 0in .0001pt;text-autospace:none;text-indent:.5in;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0in 0in .0001pt;text-indent:.5in;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Terms used herein that are not defined herein
shall have the meanings set forth in the Plan or, if not defined in the Plan,
in the Third Amended and Restated Agreement of Limited Partnership of Plains
All American Pipeline, L.P., as amended (the &#147;Partnership Agreement&#148;). By
signing below, you agree that the Phantom Units and DERs granted hereunder are
governed by the terms of the Plan.&#160;
Copies of the Plan and the Partnership Agreement are available upon
request.&#160; Please execute and return this
Agreement to me.&#160; The attached copy of
this Agreement is for your records.</font></p>

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<div style="margin:0in 0in .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">

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<table border="0" cellspacing="0" cellpadding="0" width="100%" style="border-collapse:collapse;width:100.0%;">
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  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">PLAINS AAP,
  L.P.</font></p>
  </td>
 </tr>
 <tr>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">By: PLAINS
  ALL AMERICAN GP LLC</font></p>
  </td>
 </tr>
 <tr>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">By:</font></p>
  </td>
  <td width="33%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;width:33.06%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Name:</font></p>
  </td>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Tim Moore</font></p>
  </td>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
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  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="5%" valign="top" style="padding:0in 0in 0in 0in;width:5.2%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Title:</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0in 0in 0in 0in;width:33.06%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Vice
  President &amp; General Counsel</font></p>
  </td>
  <td width="8%" valign="top" style="padding:0in 0in 0in 0in;width:8.34%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="31%" colspan="4" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;width:31.88%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="21%" valign="top" style="padding:0in 0in 0in 0in;width:21.52%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&#171;FirstName&#187;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="4%" valign="top" style="padding:0in 0in 0in 0in;width:4.74%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">SSN:</font></p>
  </td>
  <td width="20%" colspan="2" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;width:20.48%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;&nbsp;&nbsp;&#171;SSN&#187;</font></p>
  </td>
  <td width="28%" colspan="2" valign="top" style="padding:0in 0in 0in 0in;width:28.18%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="53%" colspan="5" valign="top" style="padding:0in 0in 0in 0in;width:53.4%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="5%" colspan="2" valign="top" style="padding:0in 0in 0in 0in;width:5.94%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Dated:</font></p>
  </td>
  <td width="25%" colspan="2" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;width:25.94%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="21%" valign="top" style="padding:0in 0in 0in 0in;width:21.52%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="46%" colspan="3" valign="top" style="padding:0in 0in 0in 0in;width:46.6%;">
  <p style="margin:0in 0in .0001pt;text-autospace:none;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr height="0">
  <td width="35" style="border:none;"></td>
  <td width="9" style="border:none;"></td>
  <td width="144" style="border:none;"></td>
  <td width="50" style="border:none;"></td>
  <td width="161" style="border:none;"></td>
  <td width="39" style="border:none;"></td>
  <td width="247" style="border:none;"></td>
  <td width="62" style="border:none;"></td>
 </tr>
</table>

<p align="center" style="margin:0in 0in .0001pt;text-align:center;"><font size="2" face="Times New Roman">&nbsp;</font></p>

<div style="margin:0in 0in .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">

<hr size="2" width="100%" noshade color="gray" align="left">

</font></div>

<p align="center" style="margin:0in 0in .0001pt;text-align:center;"><font size="2" face="Times New Roman">&nbsp;</font></p>

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