<PAGE>

                                                                    EXHIBIT 10.2

                             SS&C TECHNOLOGIES, INC.
                         1996 DIRECTOR STOCK OPTION PLAN

1.    Purpose.

      The purpose of this 1996 Director Stock Option Plan (the "Plan") of SS&C
Technologies, Inc. (the "Company") is to encourage ownership in the Company by
outside directors of the Company whose continued services are considered
essential to the Company's future progress and to provide them with a further
incentive to remain as directors of the Company.

2.    Administration.

      The Board of Directors shall supervise and administer the Plan. Grants of
stock options under the Plan and the amount and nature of the awards to be
granted shall be automatic in accordance with Section 5. However, all questions
concerning interpretation of the Plan or any options granted under it shall be
resolved by the Board of Directors and such resolution shall be final and
binding upon all persons having an interest in the Plan.

3.    Participation in the Plan.

      Directors of the Company who are not full-time employees of the Company or
any subsidiary of the Company ("outside directors") shall be eligible to receive
options under the Plan.

4.    Stock Subject to the Plan.

      (a)   The maximum number of shares of the Company's Common Stock, par
value $.01 per share ("Common Stock"), which may be issued under the Plan shall
be 150,000 shares, subject to adjustment as provided in Section 7.

      (b)   If any outstanding option under the Plan for any reason expires or
is terminated without having been exercised in full, the shares covered by the
unexercised portion of such option shall again become available for issuance
pursuant to the Plan.

      (c)   All options granted under the Plan shall be non-statutory options
not entitled to special tax treatment under Section 422 of the Internal Revenue
Code of 1986, as amended (the "Code").

5.    Terms, Conditions and Form of Options.

      Each option granted under the Plan shall be evidenced by a written
agreement in such form as the Board of Directors shall from time to time
approve, which agreements shall comply with and be subject to the following
terms and conditions:

      (a)   Option Grant Dates. Options shall automatically be granted to all
eligible outside directors as follows:

            (i)   each person who first becomes an eligible outside director
after the closing date (the "Closing Date") of the Company's initial public
offering of Common Stock pursuant to an effective registration statement under
the Securities Act of 1933, as amended, shall be granted an option to purchase
5,000 shares of Common Stock on the date of his or her initial election to the
Board of Directors, provided that such eligible director is elected on a date
other than the date of an Annual Meeting of Stockholders; and

<PAGE>

            (ii)  each eligible outside director shall be granted an additional
option to purchase 5,000 shares of Common Stock on the date of each Annual
Meeting of Stockholders of the Company commencing with the 1997 Annual Meeting
of Stockholders, provided that he or she continues to serve as a director
immediately following such Annual Meeting.

      (b)   Option Exercise Price. The option exercise price per share for each
option granted under the Plan shall equal (i) the last reported sales price per
share of the Company's Common Stock on the Nasdaq National Market (or, if the
Company is traded on a nationally recognized securities exchange on the date of
grant, the reported closing sales price per share of the Company's Common Stock
by such exchange) on the date of grant (or if no such price is reported on such
date such price as reported on the nearest preceding day) or (ii) if the Common
Stock is not traded on the Nasdaq National Market or an exchange, the fair
market value per share on the date of grant as most recently determined by the
Board of Directors.

      (c)   Options Non-Transferable. To the extent required to qualify for the
exemption provided by Rule 16b-3 under the Securities Exchange Act of 1934, as
amended (the "Exchange Act"), any option granted under the Plan to an optionee
shall not be transferable by the optionee other than by will or the laws of
descent and distribution or pursuant to a qualified domestic relations order as
defined by the Code or Title I of the Employee Retirement Income Security Act,
or the rules thereunder, and shall be exercisable during the optionee's lifetime
only by the optionee or the optionee's guardian or legal representative.

      (d)   Vesting Period.

            (i)   General. Each option granted under the Plan shall become
exercisable on the first anniversary of the Option Grant Date; provided,
however, that the optionee continue to serve as a director on such date.

            (ii)  Acceleration Upon Change in Control. Notwithstanding the
foregoing, each outstanding option granted under the Plan shall immediately
become exercisable in full in the event a Change in Control (as defined in
Section 8) of the Company occurs.

      (e)   Termination. Each option shall terminate, and may no longer be
exercised, on the earlier of the (i) the date 10 years after the Option Grant
Date or (ii) the date 60 days after the optionee ceases to serve as a director
of the Company; provided that, in the event an optionee ceases to serve as a
director due to his or her death or disability (within the meaning of Section
22(e)(3) of the Code or any successor provision), then the exercisable portion
of the option may be exercised, within the period of 180 days following the date
the optionee ceases to serve as a director (but in no event later than 10 years
after the Option Grant Date), by the optionee or by the person to whom the
option is transferred by will, by the laws of descent and distribution, or by
written notice pursuant to Section 5(h).

      (f)   Exercise Procedure. An option may be exercised only by written
notice to the Company at its principal office accompanied by payment in cash of
the full consideration for the shares as to which the option is exercised.

      (g)   Exercise by Representative Following Death of Director. An optionee,
by written notice to the Company, may designate one or more persons (and from
time to time change such designation), including his or her legal
representative, who, by reason of the optionee's death, shall acquire the right
to exercise all or a portion of the option. If the person or persons so
designated wish to exercise any portion of the option, they must do so within
the term of the option as provided herein. Any exercise by a representative
shall be subject to the provisions of the Plan.

                                      -2-

<PAGE>

6.    Limitation of Rights.

      (a)   No Right to Continue as a Director. Neither the Plan, nor the
granting of an option nor any other action taken pursuant to the Plan, shall
constitute or be evidence of any agreement or understanding, express or implied,
that the Company will retain the optionee as a director for any period of time.

      (b)   No Stockholders' Rights for Options. An optionee shall have no
rights as a stockholder with respect to the shares covered by his or her option
until the date of the issuance to him or her of a stock certificate therefor,
and no adjustment will be made for dividends or other rights (except as provided
in Section 7) for which the record date is prior to the date such certificate is
issued.

7.    Adjustment Provisions for Mergers, Recapitalizations and Related
      Transactions.

      If, through or as a result of any merger, consolidation, reorganization,
recapitalization, reclassification, stock dividend, stock split, reverse stock
split, or other similar transaction, (i) the outstanding shares of Common Stock
are exchanged for a different number or kind of securities of the Company or of
another entity, or (ii) additional shares or new or different shares or other
securities of the Company or of another entity are distributed with respect to
such shares of Common Stock, the Board of Directors shall make an appropriate
and proportionate adjustment in (x) the maximum number and kind of shares
reserved for issuance under the Plan, (y) the number and kind of shares or other
securities subject to then outstanding options under the Plan, and/or (z) the
price for each share subject to any then outstanding options under the Plan
(without changing the aggregate purchase price for such options), to the end
that each option shall be exercisable, for the same aggregate exercise price,
for such securities as such optionholder would have held immediately following
such event if he had exercised such option immediately prior to such event. No
fractional shares will be issued under the Plan on account of any such
adjustments.

8.    Change in Control. For purposes of the Plan, a "Change in Control"
shall be deemed to have occurred only if any of the following events occurs: (i)
any "person", as such term is used in Sections 13(d) and 14(d) of the Exchange
Act (other than the Company, any trustee or other fiduciary holding securities
under an employee benefit plan of the Company, or any corporation owned directly
or indirectly by the stockholders of the Company in substantially the same
proportion as their ownership of stock of the Company), is or becomes the
"beneficial owner" (as defined in Rule 13d-3 under the Exchange Act), directly
or indirectly, of securities of the Company representing 50% or more of the
combined voting power of the Company's then outstanding securities; (ii) the
stockholders of the Company approve a merger or consolidation of the Company
with any other corporation, other than a merger or consolidation which would
result in the voting securities of the Company outstanding immediately prior
thereto continuing to represent (either by remaining outstanding or by being
converted into voting securities of the surviving entity) more than 50% of the
combined voting power of the voting securities of the Company or such surviving
entity outstanding immediately after such merger or consolidation; (iii) the
stockholders of the Company approve a plan of complete liquidation of the
Company or an agreement for the sale or disposition by the Company of all or
substantially all of the Company's assets; or (iv) individuals who, on the date
on which the Plan was adopted by the Board of Directors, constituted the Board
of Directors of the Company, together with any new director whose election by
the Board of Directors or nomination for election by the Company's stockholders
was approved by a vote of at least a majority of the directors then still in
office who were directors on the date on which the Plan was adopted by the Board
of Directors or whose election or nomination was previously so approved, cease
for any reason to constitute at least a majority of the Board of Directors.

9.    Modification, Extension and Renewal of Options.

                                      -3-

<PAGE>

      The Board of Directors shall have the power to modify or amend outstanding
options; provided, however, that no modification or amendment may (i) have the
effect of altering or impairing any rights or obligations of any option
previously granted without the consent of the optionee, or (ii) modify the
number of shares of Common Stock subject to the option (except as provided in
Section 7).

10.   Termination and Amendment of the Plan.

      The Board of Directors may suspend, terminate or discontinue the Plan or
amend it in any respect whatsoever; provided, however, that without approval of
the stockholders of the Company, no amendment may (i) increase the number of
shares subject to the Plan (except as provided in Section 7), (ii) materially
modify the requirements as to eligibility to receive options under the Plan, or
(iii) materially increase the benefits accruing to participants in the Plan; and
provided further that the Board of Directors may not amend the provisions of
Sections 3, 5(a), 5(b) or 5(c) more frequently than once every six months, other
than to comply with changes in the Code or the rules thereunder.

11.   Notice.

      Any written notice to the Company required by any of the provisions of the
Plan shall be addressed to the Treasurer of the Company and shall become
effective when it is received.

12.   Governing Law.

      The Plan and all determinations made and actions taken pursuant hereto
shall be governed by the laws of the State of Delaware.

13.   Stockholder Approval.

      The Plan is conditional upon stockholder approval of the Plan within one
year from its date of adoption by the Board of Directors. No option under the
Plan may be exercised until such stockholder approval is obtained, and the Plan
and all options granted under the Plan shall be null and void if the Plan is not
so approved by the Company's stockholders.

                             Adopted by the Board of Directors on April 1, 1996.
                             Approved by the Stockholders on April 1, 1996.

                                      -4-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 1
                                       TO
                         1996 DIRECTOR STOCK OPTION PLAN

      The 1996 Director Stock Option Plan (the "Plan") of SS&C Technologies,
Inc. is hereby amended as follows (capitalized terms used herein and not defined
herein shall have the respective meaning ascribed to such terms in the Plan):

1.    The reference to Section 5(h) at the end of Section 5(e) of the Plan shall
be amended to refer to Section 5(f).

2.    Section 10 of the Plan shall be deleted in its entirety and replaced with
the following:

      "10. Termination and Amendment of the Plan. The Board of Directors may
      suspend, terminate or discontinue the Plan or amend it in any respect
      whatsoever."

Except as aforesaid, the Plan shall remain in full force and effect.

                         Adopted by the Board of Directors on October 30, 1996.

                                      -5-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 2
                                       TO
                   1996 DIRECTOR STOCK OPTION PLAN, AS AMENDED

1.    The 1996 Director Stock Option Plan, as amended (the "Plan"), is hereby
amended to delete subsection 5(d) thereof and replace such subsection in
its entirety with the following:

            "(d)  Vesting Period. Each option granted under the Plan shall be
            exercisable in full immediately upon the Option Grant Date."

2.    The Plan is hereby amended to delete section 8 thereof and replace such
section in its entirety with the following:

            "8.   Intentionally deleted."

3.    Except as aforesaid, the Plan shall remain in full force and effect.

                              Adopted by the Board of Directors on May 5, 1999.

                                      -6-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 3
                                       TO
                   1996 DIRECTOR STOCK OPTION PLAN, AS AMENDED

1.    The 1996 Director Stock Option Plan, as amended (the "Plan"), is hereby
amended to delete subsection 4(a) thereof and replace such subsection in its
entirety with the following:

            "4(a) The maximum number of shares of the Company's Common Stock,
            par value $.01 per share ("Common Stock"), which may be issued under
            the Plan shall be 300,000 shares, subject to adjustment as provided
            in Section 7."

2.    The Plan is hereby amended to delete section 5(a) thereof and replace such
section in its entirety with the following:

      "5(a) Option Grant Dates. Options shall automatically be granted to all
eligible outside directors as follows:

            (i)   each person who first becomes an eligible outside director
                  after the 2000 Annual Meeting of Stockholders of the Company
                  shall be granted an option to purchase 10,000 shares of Common
                  Stock on the date of his or her initial election to the Board
                  of Directors, provided that such eligible director is elected
                  on a date other than the date of an Annual Meeting of
                  Stockholders; and

            (ii)  each eligible outside director shall be granted an option to
                  purchase 10,000 shares of Common Stock on the date of each
                  Annual Meeting of Stockholders of the Company commencing with
                  the 2000 Annual Meeting of Stockholders, provided that he or
                  she continues to serve as a director immediately following
                  such Annual Meeting."

3.    Except as aforesaid, the Plan shall remain in full force and effect.

                          Adopted by the Board of Directors on February 7, 2000.
                          Approved by the Stockholders on May 23, 2000.

                                      -7-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 4
                                       TO
                   1996 DIRECTOR STOCK OPTION PLAN, AS AMENDED

1.    The Plan is hereby amended to delete section 5(a) thereof and replace such
      section in its entirety with the following:

            "5(a) Option Grant Dates. Options shall automatically be granted to
            all eligible outside directors as follows:

                  (i)   each person who first becomes an eligible outside
                        director after the 2002 Annual Meeting of Stockholders
                        of the Company shall be granted an option to purchase
                        5,000 shares of Common Stock on the date of his or her
                        initial election to the Board of Directors, provided
                        that such eligible director is elected on a date other
                        than the date of an Annual Meeting of Stockholders; and

                  (ii)  each eligible outside director shall be granted an
                        option to purchase 5,000 shares of Common Stock on the
                        date of each Annual Meeting of Stockholders of the
                        Company commencing with the 2002 Annual Meeting of
                        Stockholders, provided that he or she continues to serve
                        as a director immediately following such annual
                        Meeting."

2.    Except as aforesaid, the Plan shall remain in full force and effect.

                              Adopted by the Board of Directors on May 22, 2002.

                                      -8-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 5
                                       TO
                   1996 DIRECTOR STOCK OPTION PLAN, AS AMENDED

      The Director Stock Option Plan (the "Plan") of SS&C Technologies, Inc. is
hereby amended as follows (capitalized terms used herein and not defined herein
shall have the respective meanings ascribed to such terms in the Plan):

      1. Subsection 4(a) of the Plan is deleted and replaced with the following:

            "The maximum number of shares of the Company's common stock, par
            value $.01 per share ("Common Stock"), which may be issued under the
            Plan shall be 675,000 shares (after giving effect to the Company's
            three-for-two stock split payable March 5, 2004 to stockholders of
            record February 20, 2004), subject to adjustment as provided in
            section 7."

      2. Except as amended hereby, the Plan remains in full force and effect.

                          Adopted by the Board of Directors on February 5, 2004.
                          Approved by the Stockholders on May 20, 2004.

                                      -9-

<PAGE>

                             SS&C TECHNOLOGIES, INC.

                                 AMENDMENT NO. 6
                                       TO
                   1996 DIRECTOR STOCK OPTION PLAN, AS AMENDED

      The Director Stock Option Plan (the "Plan") of SS&C Technologies, Inc. is
hereby amended as follows (capitalized terms used herein and not defined herein
shall have the respective meanings ascribed to such terms in the Plan):

1.    The Plan is hereby amended to delete section 5(a) thereof and replace such
      section in its entirety with the following:

            "5(a) Option Grant Dates. Options shall automatically be granted to
            all eligible outside directors as follows:

                  (i)   each person who first becomes an eligible outside
                        director on or after March 11, 2005 shall be granted an
                        option to purchase 5,000 shares of Common Stock (after
                        giving effect to the Company's three-for-two stock split
                        payable March 5, 2004 to stockholders of record on
                        February 20, 2004) on the date of his or her initial
                        election to the Board of Directors, provided that such
                        eligible director is elected on a date other than the
                        date of an Annual Meeting of Stockholders; and

                  (ii)  each eligible outside director shall be granted an
                        option to purchase 5,000 shares of Common Stock (after
                        giving effect to the Company's three-for-two stock split
                        payable March 5, 2004 to stockholders of record on
                        February 20, 2004) on the date of each Annual Meeting of
                        Stockholders of the Company commencing with the 2005
                        Annual Meeting of Stockholders, provided that he or she
                        continues to serve as a director immediately following
                        such Annual Meeting."

2.    Except as aforesaid, the Plan shall remain in full force and effect.

                           Adopted by the Board of Directors on March 11, 2005.

                                      -10-

<PAGE>

                             SS&C TECHNOLOGIES, INC.
                         1996 DIRECTOR STOCK OPTION PLAN

                         DIRECTOR STOCK OPTION AGREEMENT

      1. Grant of Option. SS&C Technologies, Inc., a Delaware corporation (the
"Company"), hereby grants to [________________] (the "Optionee"), an option,
pursuant to the Company's 1996 Director Stock Option Plan, as amended (the
"Plan"), to purchase an aggregate of [_______] shares of Common Stock, $.01 par
value per share ("Common Stock"), of the Company at an exercise price of
$[_____] per share, purchasable as set forth in, and subject to the terms and
conditions of, this option and the Plan.

      2. Non-Statutory Stock Option. This option is not intended to qualify as
an incentive stock option within the meaning of Section 422 of the Internal
Revenue Code of 1986, as amended, and any regulations thereunder (the "Code").

      3. Vesting, Exercise of Option and Provisions for Termination.

            (a) Vesting Schedule. Except as otherwise provided in this
Agreement, this option may be exercised at any time, and from time to time, on
or after the date of grant but prior to the tenth anniversary of the date of
grant (hereinafter the "Expiration Date"). This option may not be exercised at
any time on or after the Expiration Date.

            (b) Exercise Procedure. Subject to the conditions set forth in this
Agreement, this option shall be exercised by the Optionee's delivery of written
notice of exercise to the Treasurer of the Company, specifying the number of
shares to be purchased and the purchase price to be paid therefor and
accompanied by payment in full in accordance with Section 4. Such exercise shall
be effective upon receipt by the Treasurer of the Company of such written notice
together with the required payment. The Optionee may purchase less than the
number of shares of Common Stock covered hereby.

            (c) Exercise by Representative Following Death of Director. The
Optionee, by written notice to the Treasurer of the Company, may designate one
or more persons (and from time to time change such designation), including his
or her legal representative, who, by reason of the Optionee's death, shall
acquire the right to exercise all or a portion of this option. If the person or
persons so designated wish to exercise any portion of this option, they must do
so within the term of this option as provided herein. Any exercise by a
representative shall be subject to the provisions of the Plan.

            (d) Termination of Service as a Director. If the Optionee ceases to
serve as a director of the Company for any reason, then, except as provided in
Section 3(e), the right to exercise this option shall terminate 60 days after
such cessation (but in no event after the Expiration Date).

            (e) Exercise Period Upon Death or Disability. If the Optionee ceases
to serve as a director due to his or her death or disability (within the meaning
of Section 22(e)(3) of the Code, or any successor provision) prior to the
Expiration Date, then the exercisable portion of this option may be exercised,
within the period of 180 days following the date the Optionee ceases to serve as
a director (but in no event later than the Expiration Date), by the Optionee or
by the person to whom this option is transferred by will, by the laws of descent
and distribution, or by written notice pursuant to Section 3(c).

      4. Payment of Purchase Price. Payment of the purchase price for shares of
Common Stock purchased upon exercise of this option shall be made by delivery to
the Company of cash or a check to the order of the Company in an amount equal to
the purchase price of such shares.

<PAGE>

      5. Delivery of Shares; Compliance With Securities Laws, Etc.

            (a) General. The Company shall, upon payment of the option price for
the number of shares purchased and paid for, make prompt delivery of such shares
to the Optionee; provided that if any law or regulation requires the Company to
take any action with respect to such shares before the issuance thereof, then
the date of delivery of such shares shall be extended for the period necessary
to complete such action.

            (b) Listing, Qualification, Etc. This option shall be subject to the
requirement that if, at any time, counsel to the Company shall determine that
the listing, registration or qualification of the shares subject hereto upon any
securities exchange or under any state or federal law, or the consent or
approval of any governmental or regulatory body, or that the disclosure of
non-public information or the satisfaction of any other condition is necessary
as a condition of, or in connection with, the issuance or purchase of shares
hereunder, this option may not be exercised, in whole or in part, unless such
listing, registration, qualification, consent or approval, disclosure or
satisfaction of such other condition shall have been effected or obtained on
terms acceptable to the Board of Directors. Nothing herein shall be deemed to
require the Company to apply for, effect or obtain such listing, registration,
qualification or disclosure, or to satisfy such other condition.

      6. Nontransferability of Option. Except as provided in Section 3(c), to
the extent required to qualify for the exemption provided by Rule 16b-3 under
the Securities Exchange Act of 1934, as amended, this option shall not be
transferable by the Optionee other than by will or the laws of descent and
distribution or pursuant to a qualified domestic relations order as defined by
the Code or Title I of the Employee Retirement Income Security Act, or the rules
thereunder, and shall be exercisable during the Optionee's lifetime only by the
Optionee or the Optionee's guardian or legal representative. Upon any attempt to
transfer, assign, pledge, hypothecate or otherwise dispose of this option or of
such rights contrary to the provisions hereof, or upon the levy of any
attachment or similar process upon this option or such rights, this option and
such rights shall, at the election of the Company, become null and void.

      7. No Right to Continue as a Director. Neither the Plan, nor the granting
of this option nor any other action taken pursuant to the Plan, shall constitute
or be evidence of any agreement or understanding, express or implied, that the
Company will retain the Optionee as a director for any period of time.

      8. Rights as a Stockholder. The Optionee shall have no rights as a
stockholder with respect to any shares of Common Stock which may be purchased by
exercise of this option (including, without limitation, any rights to receive
dividends or non-cash distributions with respect to such shares) unless and
until a certificate representing such shares is duly issued and delivered to the
Optionee. No adjustment shall be made for dividends or other rights for which
the record date is prior to the date such stock certificate is issued.

      9. Adjustment Provisions.

            (a) General. If, through or as a result of any merger,
consolidation, reorganization, recapitalization, reclassification, stock
dividend, stock split, reverse stock split or other similar transaction, (i) the
outstanding shares of Common Stock are exchanged for a different number or kind
of securities of the Company or of another entity, or (ii) additional shares or
new or different shares or other securities of the Company or of another entity
are distributed with respect to such shares of Common Stock, the Board of
Directors shall make an appropriate and proportionate adjustment in the price
for each share subject to this option (without changing the aggregate purchase
price for this option), to the end that this option shall be exercisable, for
the same aggregate exercise price, for such securities as the Optionee

                                      -2-

<PAGE>

would have held immediately following such event if he had exercised this option
immediately prior to such event. No fractional shares will be issued to the
Optionee on account of any such adjustments.

            (b) Limits on Adjustments. No adjustment shall be made under this
Section 9 which would (i) have the effect of altering or impairing any rights or
obligations of this option without the consent of the Optionee, or (ii) modify
the number of shares of Common Stock subject to this option (except as provided
in Section 9(a)).

      10. Withholding Taxes. The Company's obligation to deliver shares upon the
exercise of this option shall be subject to the Optionee's satisfaction of all
applicable federal, state and local income and employment tax withholding
requirements.

      11. Miscellaneous.

            (a) Except as provided herein, this option may not be amended or
otherwise modified unless evidenced in writing and signed by the Company and the
Optionee.

            (b) All notices under this option shall be mailed (including by
electronic mail) or delivered by hand to the parties at their respective
addresses set forth beneath their names below or at such other address as may be
designated in writing by either of the parties to one another.

            (c) This option shall be governed by and construed in accordance
with the laws of the State of Delaware.

Date of Grant: ______________               SS&C TECHNOLOGIES, INC.

                                            By:_____________________________

                                            Title:__________________________

                                            Address:

                                            80 Lamberton Road
                                            Windsor, CT 06095

                                      -3-

<PAGE>

                              OPTIONEE'S ACCEPTANCE

      The undersigned hereby accepts the foregoing option and agrees to the
terms and conditions thereof. The undersigned hereby acknowledges receipt of a
copy of the Company's 1996 Director Stock Option Plan, as amended.

                                            OPTIONEE

                                            ____________________________________
                                            [Name]

                                            Address:

                                            ____________________________________

                                            ____________________________________

                                      -4-