<SEC-DOCUMENT>0001080657-14-000004.txt : 20140428
<SEC-HEADER>0001080657-14-000004.hdr.sgml : 20140428
<ACCEPTANCE-DATETIME>20140428172233
ACCESSION NUMBER:		0001080657-14-000004
CONFORMED SUBMISSION TYPE:	DEF 14A
PUBLIC DOCUMENT COUNT:		1
CONFORMED PERIOD OF REPORT:	20140428
FILED AS OF DATE:		20140428
DATE AS OF CHANGE:		20140428
EFFECTIVENESS DATE:		20140428

FILER:

	COMPANY DATA:	
		COMPANY CONFORMED NAME:			NETREIT, INC.
		CENTRAL INDEX KEY:			0001080657
		STANDARD INDUSTRIAL CLASSIFICATION:	REAL ESTATE INVESTMENT TRUSTS [6798]
		IRS NUMBER:				330841255
		STATE OF INCORPORATION:			MD
		FISCAL YEAR END:			1231

	FILING VALUES:
		FORM TYPE:		DEF 14A
		SEC ACT:		1934 Act
		SEC FILE NUMBER:	000-53673
		FILM NUMBER:		14790519

	BUSINESS ADDRESS:	
		STREET 1:		1282 PACIFIC OAKS PLACE
		CITY:			ESCONDIDO
		STATE:			CA
		ZIP:			92029-2900
		BUSINESS PHONE:		760-471-8536

	MAIL ADDRESS:	
		STREET 1:		1282 PACIFIC OAKS PLACE
		CITY:			ESCONDIDO
		STATE:			CA
		ZIP:			92029-2900

	FORMER COMPANY:	
		FORMER CONFORMED NAME:	NETREIT
		DATE OF NAME CHANGE:	19990225
</SEC-HEADER>
<DOCUMENT>
<TYPE>DEF 14A
<SEQUENCE>1
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">VOTE BY INTERNET - www.proxyvote.com</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Use the Internet to transmit your voting instructions and for electronic delivery of</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">information up until 11:59 P.M. Eastern Time the day before the cut-off date or</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">meeting date. Have your proxy card in hand when you access the web site and</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">follow the instructions to obtain your records and to create an electronic voting</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">instruction form.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">ELECTRONIC DELIVERY OF FUTURE PROXY MATERIALS</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">If you would like to reduce the costs incurred by our company in mailing proxy</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">materials, you can consent to receiving all future proxy statements, proxy cards</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">and annual reports electronically via e-mail or the Internet. To sign up for</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">electronic delivery, please follow the instructions above to vote using the Internet</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">and, when prompted, indicate that you agree to receive or access proxy materials</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">electronically in future years.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; FONT-STYLE: italic; TEXT-ALIGN: left">Netreit, Inc.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; FONT-STYLE: italic; TEXT-ALIGN: left">c/o Broadridge</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">VOTE BY PHONE - 1-800-690-6903</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; FONT-STYLE: italic; TEXT-ALIGN: left">P.O. Box 1342</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Use any touch-tone telephone to transmit your voting instructions up until 11:59</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; FONT-STYLE: italic; TEXT-ALIGN: left">Brentwood, NY 11717</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">P.M. Eastern Time the day before the cut-off date or meeting date. Have your</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">proxy card in hand when you call and then follow the instructions.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">VOTE BY MAIL</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Mark, sign and date your proxy card and return it in the postage-paid envelope we</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">have provided or return it to Vote Processing, c/o Broadridge, 51 Mercedes Way,</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Edgewood, NY 11717.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">TO VOTE, MARK BLOCKS BELOW IN BLUE OR BLACK INK AS FOLLOWS:</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: right">KEEP THIS PORTION FOR YOUR RECORDS</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: center">KEEP THIS PORTION FOR YOUR RECORDS</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">DETACH AND RETURN THIS PORTION ONLY</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: center">THIS PROXY CARD IS VALID ONLY WHEN SIGNED AND DATED.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">To withhold authority to vote for any</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">For</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">Withhold</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">For All</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">individual nominee(s), mark "For All</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">All</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">All</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: center">Except</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Except" and write the number(s) of the</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">The Board of Directors recommends you vote</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">nominee(s) on the line below.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold; COLOR: #000000; TEXT-ALIGN: left">FOR the following:</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">01 William H. Allen&#160; 02 David T. Bruen&#160; 03 Shirley Y. Bullard&#160; 04 Larry G. Dubose&#160; 05 Kenneth W. Elsberry</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">06 Jack K. Heilbron 07 Sumner J. Rollings 08 Thomas E. Schwartz</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">The Board of Directors recommends you vote FOR the following proposal 2.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">2 Ratification of the appointment of Squar, Milner, Peterson, Miranda &amp; Williamson, LLP as our independent Registered Public</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Accounting Firm.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">For</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Against</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Abstain</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left"><font style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; FONT-WEIGHT: bold">NOTE: </font>To vote and otherwise represent the undersigned on such other matters as may properly come before the meeting or any</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">adjournment or postponement thereof.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">For address change/comments, mark here.</div>
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<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">(see reverse for instructions)</div>
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<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
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<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 84.62%" colspan="11">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Please sign exactly as your name(s) appear(s) hereon. When signing as</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 84.62%" colspan="11">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">attorney, executor, administrator, or other fiduciary, please give full</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 84.62%" colspan="11">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">title as such. Joint owners should each sign personally. All holders must</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 84.62%" colspan="11">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">sign. If a corporation or partnership, please sign in full corporate or</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 84.62%" colspan="11">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">partnership name, by authorized officer.</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
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<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 30.77%" colspan="4"></td>
<td style="VERTICAL-ALIGN: bottom; BORDER-BOTTOM: #000000 2px solid; WIDTH: 7.69%"></td>
</tr>

<tr style="BACKGROUND-COLOR: #ffffff">
<td style="VERTICAL-ALIGN: bottom; WIDTH: 38.46%" colspan="5">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Signature [PLEASE SIGN WITHIN BOX]</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Date</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%"></td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 30.77%" colspan="4">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Signature [Joint Owners]</div>
</td>
<td style="VERTICAL-ALIGN: bottom; WIDTH: 7.69%">
<div style="FONT-SIZE: 10pt; FONT-FAMILY: ''Times New Roman'', Times, serif; COLOR: #000000; TEXT-ALIGN: left">Date</div>
</td>
</tr>
</table>

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