Form of senior debt security-medium-term note



 Exhibit 4.01 
 LEHMAN BROTHERS HOLDINGS INC. 
 Bearish Return Optimization Securities with Partial Protection Linked to the Dow Jones
Industrial AverageSM Due August 29, 2008 
  

			
	Number R-1	  	$7,300,000
	ISIN US52520W3824	  	CUSIP 52520W382

 See Reverse for Certain Definitions 
 THIS SECURITY (THIS “SECURITY”) IS A GLOBAL SECURITY WITHIN THE MEANING OF THE INDENTURE HEREINAFTER REFERRED TO AND IS REGISTERED IN
THE NAME OF A DEPOSITORY OR A NOMINEE THEREOF. UNLESS AND UNTIL IT IS EXCHANGED IN WHOLE OR IN PART FOR SECURITIES IN CERTIFICATED FORM, THIS SECURITY MAY NOT BE TRANSFERRED EXCEPT AS A WHOLE BY THE DEPOSITORY TO A NOMINEE OF THE DEPOSITORY OR BY A
NOMINEE OF THE DEPOSITORY TO SUCH DEPOSITORY OR ANOTHER NOMINEE OF THE DEPOSITORY OR BY THE DEPOSITORY OR ANY SUCH NOMINEE TO A SUCCESSOR DEPOSITORY OR A NOMINEE OF SUCH SUCCESSOR DEPOSITORY. UNLESS THIS SECURITY IS PRESENTED BY AN AUTHORIZED
REPRESENTATIVE OF THE DEPOSITORY TO LEHMAN BROTHERS HOLDINGS INC. OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE OR PAYMENT, AND ANY SECURITY ISSUED IS REGISTERED IN THE NAME OF CEDE & CO. OR IN SUCH OTHER NAME AS REQUESTED BY AN
AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY (AND ANY PAYMENT IS MADE TO CEDE & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE
BY OR TO ANY PERSON IS WRONGFUL INASMUCH AS THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN INTEREST HEREIN. 
 LEHMAN BROTHERS
HOLDINGS INC., a corporation duly organized and existing under the laws of the State of Delaware (hereinafter called the “Company”), for value received, hereby promises to pay to CEDE & CO. or registered assigns, at the
office or agency of the Company in the Borough of Manhattan, The City of New York, on the Maturity Date, in such coin or currency of the United States of America at the time of payment shall be legal tender for the payment of public and private
debts, for each $10 principal amount of the Securities represented hereby, an amount equal to the Payment at Maturity. THE SECURITIES REPRESENTED HEREBY SHALL NOT BEAR ANY INTEREST. 
 Any amount payable hereon on the Maturity Date will be paid only upon presentation and surrender of this Security. 
 REFERENCE IS HEREBY MADE TO THE FURTHER PROVISIONS OF THIS SECURITY SET FORTH ON THE REVERSE HEREOF WHICH FURTHER PROVISIONS SHALL FOR ALL PURPOSES HAVE
THE SAME EFFECT AS IF SET FORTH AT THIS PLACE. 







 Dow Jones Industrial AverageSM is a service mark of Dow Jones & Company, Inc. and has been licensed for use by the Company. The Securities are not sponsored, endorsed, sold or
promoted by Dow Jones & Company, Inc., or any of its subsidiaries or affiliates, and Dow Jones & Company, Inc. makes no representation regarding the advisability of investing in the Securities. 
 This Security shall not be valid or become obligatory for any purpose until the certificate of authentication hereon shall have been signed by the
Trustee under the Indenture referred to on the reverse hereof. 
  

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 IN WITNESS WHEREOF, Lehman Brothers Holdings Inc. has caused this instrument to be signed by its
Chairman of the Board, its President, its Vice Chairman, its Chief Financial Officer, one of its Vice Presidents or its Treasurer, by manual or facsimile signature under its corporate seal, attested by its Secretary or one of its Assistant
Secretaries by manual or facsimile signature. 
  

							
	 Dated: June 29, 2007
	 	LEHMAN BROTHERS HOLDINGS INC.	 	
				
	 [SEAL]
	 	By:	 	  
	 	
		 		 	Vice President	 	
				
		 	Attest:	 	  
	 	
		 		 	Assistant Secretary	 	

  
 TRUSTEE’S CERTIFICATE OF
AUTHENTICATION 
 This is one of the Securities of the series designated therein referred to in the within-mentioned Indenture. 
  

			
	CITIBANK, N.A.
	as Trustee
		
	By:	 	  

		 	    Authorized Officer

  

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 Reverse of Security 
 This Security is one of a duly authorized series of Securities of the Company designated as Bearish Return Optimization Securities with Partial Protection Linked to the Dow Jones Industrial AverageSM Due August 29, 2008 (herein called the “Securities”). The Company may, without the consent of the
holders of the Securities, create and issue additional notes ranking equally with the Securities and otherwise similar in all respects so that such further notes shall be consolidated and form a single series with the Securities; provided that no
additional notes can be issued if an Event of Default has occurred with respect to the Securities. This series of Securities is one of an indefinite number of series of debt securities of the Company, issued and to be issued under an indenture,
dated as of September 1, 1987, as amended (herein called the “Indenture”), duly executed and delivered by the Company and Citibank, N.A., as trustee (herein called the “Trustee”, which term includes any
successor trustee under the Indenture), to which Indenture and all indentures supplemental thereto reference is hereby made for a description of the rights, limitations of rights, obligations, duties and immunities thereunder of the Company, the
Trustee and the Holders of the Securities. 
 The Payment at Maturity, at the request of the Trustee, shall be determined by the Calculation
Agent pursuant to the Calculation Agency Agreement. The Trustee shall fully rely on the determination by the Calculation Agent of the Payment at Maturity and shall have no duty to make any such determination. The Calculation Agent will provide
written notice to the Trustee at its New York office, on which notice the Trustee may conclusively rely, of the Payment at Maturity on or prior to 11:00 a.m. on the Business Day preceding the Maturity Date. 
 All calculations with respect to the Index Ending Level and the Index Return will be rounded to the nearest one hundred-thousandth, with five
one-millionths rounded upward (e.g., .876545 would be rounded to .87655); all dollar amounts related to determination of the payment per $10 principal amount note at maturity will be rounded to the nearest ten-thousandth, with five one
hundred-thousandths rounded upward (e.g., .76545 would be rounded up to .7655); and all dollar amounts paid on the aggregate principal amount of Securities per Holder will be rounded to the nearest cent, with one-half cent rounded upward.

 This Security is not subject to any sinking fund. 
 If an Event of Default with respect to the Securities shall occur and be continuing, the amounts payable on all of the Securities may be declared due and payable in the manner and with the effect provided in the
Indenture. The amount payable to the Holder hereof upon any acceleration permitted under the Indenture will be equal to the Payment at Maturity calculated as though the date of acceleration were the Maturity Date and the fifth Business Day
immediately preceding the date of acceleration were the Final Valuation Date. If the maturity of the Securities is accelerated because of an Event of Default, the Company shall, or shall cause the Calculation Agent to, provide written notice to the
Trustee at its New York office, on which notice the Trustee may conclusively rely, and to The Depository Trust Company of the cash amount due with respect to the Securities as promptly as possible and in no event later than two Business Days after
the date of acceleration. 
 The Indenture contains provisions permitting the Company and the Trustee, with the consent of the holders of
not less than 66 2/3% in aggregate principal amount of each series of 








 
Securities at the time Outstanding to be affected (each series voting as a class), evidenced as in the Indenture provided, to execute supplemental indentures
adding any provisions to, or changing in any manner or eliminating any of the provisions of the Indenture or of any supplemental indenture or modifying in any manner the rights of the holders of the Securities of all such series; provided,
however, that no such supplemental indenture shall, among other things, (i) change the fixed maturity of any Security, or reduce the principal amount thereof, or reduce the rate or extend the time of payment of interest thereon,
if any, or reduce any premium payable on redemption, or make the principal thereof, or premium, if any, or interest thereon, if any, payable in any coin or currency other than that hereinabove provided, without the consent of the holder of each
Security so affected, or (ii) change the place of payment on any Security, or impair the right to institute suit for payment on any Security, or reduce the aforesaid percentage of Securities, the holders of which are required to consent to any
such supplemental indenture, without the consent of the holders of each Security so affected. It is also provided in the Indenture that, prior to any declaration accelerating the maturity of any series of Securities, the holders of a majority in
aggregate principal amount of the Securities of such series Outstanding may on behalf of the holders of all the Securities of such series waive any past default or Event of Default under the Indenture with respect to such series and its
consequences, except a default in the payment of interest, if any, or the principal of, or premium, if any, on any of the Securities of such series, or in the payment of any sinking fund installment or analogous obligation with respect to Securities
of such series. Any such consent or waiver by the Holder of this Security shall be conclusive and binding upon such Holder and upon all future holders and owners of this Security and any Securities which may be issued in exchange or substitution
hereof, irrespective of whether or not any notation thereof is made upon this Security or such other Securities. 
 No reference herein to
the Indenture and no provision of this Security or of the Indenture shall alter or impair the obligation of the Company, which is absolute and unconditional, to pay the Payment at Maturity with respect to this Security. 
 The Securities are issuable in denominations of $10 and any whole multiples of $10. 
 The Company, the Trustee, and any agent of the Company or of the Trustee may deem and treat the registered holder (the “Holder”) hereof
as the absolute owner of this Security (whether or not this Security shall be overdue and notwithstanding any notation of ownership or other writing hereon), for the purpose of receiving payment hereof, or on account hereof, and for all other
purposes and neither the Company nor the Trustee nor any agent of the Company or of the Trustee shall be affected by any notice to the contrary. All such payments made to or upon the order of such registered holder shall, to the extent of the sum or
sums paid, effectually satisfy and discharge liability for moneys payable on this Security. 
 No recourse for the payment of the principal
of, premium, if any, or interest on this Security, or for any claim based hereon or otherwise in respect hereof, and no recourse under or upon any obligation, covenant or agreement of the Company in the Indenture or any indenture supplemental
thereto or in any Security, or because of the creation of any indebtedness represented thereby, shall be had against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or of any successor
corporation, either directly or through the Company or any successor corporation, whether by virtue of any constitution, statute 

  

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or rule of law or by the enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance hereof and as part of the
consideration for the issue hereof, expressly waived and released. 
 As provided in the Indenture and subject to certain limitations
therein set forth, the transfer of this Security is registrable in the Security Register, upon surrender of this Security for registration of transfer at the Corporate Trust Office or agency in a Place of Payment for this Security, duly endorsed by,
or accompanied by a written instrument of transfer in form satisfactory to the Company and the Security Registrar duly executed by, the Holder hereof or such Holder’s attorney duly authorized in writing, and thereupon one or more new Securities
of this series or of like tenor and of authorized denominations and for the same aggregate principal amount, will be issued to the designated transferee or transferees. 
 The Company intends to treat, and by purchasing this Security, the Holder agrees to treat, for all tax purposes, this Security as a cash-settled financial contract, rather than as a debt instrument. 
 THE INDENTURE AND THIS SECURITY SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF NEW YORK. 
 Definitions 
 Set forth below are definitions of the
terms used in this Security. 
 “Business Day”, notwithstanding any provision in the Indenture, shall mean any day that is
not a Saturday or Sunday and that is not a day on which banking institutions in the City of New York are authorized or obligated by law to close. 
 “Calculation Agency Agreement” shall mean the Calculation Agency Agreement, dated as of December 21, 2006 between the Company and the Calculation Agent, as amended from time to time, or any successor calculation agency
agreement. 
 “Calculation Agent” shall mean the person that has entered into an agreement with the Company providing for,
among other things, the determination of the Payment at Maturity, which term shall, unless the context otherwise requires, include its successors and assigns. The initial Calculation Agent shall be Lehman Brothers Inc. 
 “Closing Price” of a security, on any particular day, means the last reported sales price for that security on the Relevant Exchange at
the scheduled weekday closing time of the regular trading session of the Relevant Exchange. If, however, the security is not listed or traded on a bulletin board, then the Closing Price of the security will be determined using the average execution
price per share that an affiliate of the Company pays or receives upon the purchase or sale of the security used to hedge the Company’s obligations under the Securities. 
 “Company” shall have the meaning set forth on the face of this Security. 
 “Downside Protection Level” shall mean 10%. 
  

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 “Final Valuation Date” shall mean August 22, 2008, provided, however, that if the
scheduled Final Valuation Date is not a Trading Day or if there is a Market Disruption Event on such day, the Final Valuation Date will be the first succeeding Trading Day during which no Market Disruption Event shall have occurred or be continuing;
provided, however, that the Index Ending Level will not be determined on a date later than the eighth scheduled Trading Day after the scheduled Final Valuation Date; and if such day is not a Trading Day, or there is a Market Disruption Event on such
date, the Calculation Agent will determine the Index Ending Level on such date in accordance with the formula for and method of calculating the Index Closing Level last in effect prior to commencement of the Market Disruption Event (or prior to the
non-Trading Day), using the Closing Price (or, if trading in the relevant securities has been materially suspended or materially limited, its good faith estimate of the Closing Price that would have prevailed but for such suspension or limitation or
non-Trading Day) on such eighth scheduled Trading Day of each security most recently included in the Index. 
 “Holder”
shall have the meaning set forth on the reverse of this Security. 
 “Indenture” shall have the meaning set forth on the
reverse of this Security. 
 “Index” shall mean the Dow Jones Industrial AverageSM as calculated, published and disseminated by Dow Jones & Company, Inc. 
 “Index Closing Level” as determined by the Calculation Agent, shall mean, with respect to any Trading Day, the closing level of the
Index or any Successor Index, as the case may be, at the regular official weekday close of the principal trading session of the Relevant Exchange or market for the Index or the Successor Index, as the case may be, on such day, or as determined by
the Calculation Agent pursuant to the Calculation Agency Agreement as described below under “Discontinuation of the Index; Alteration of Method of Calculation.” 
 “Index Ending Level” is the Index Closing Level on the Final Valuation Date. 
 “Index Return,” as calculated by the Calculation Agent, is calculated as follows for the Index: 
 Index Ending Level –Index Starting Level 
 Index Starting Level 
 “Index Starting Level” shall equal 13,352.05, which was the Index Closing Level on the
Trade Date. 
 “Leverage Factor” is 5. 
 “Market Disruption Event”, with respect to the Index (or any Successor Index), means: 
 (1)    a suspension, absence or material limitation of trading of stocks then constituting 20% or more of the level of the Index (or the relevant Successor Index) on the 

  

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Relevant Exchanges for such securities at any time during the one hour period preceding the close of the principal trading session on such Relevant Exchange;

 (2)    a breakdown or failure in the price and trade reporting systems of the primary market of any Relevant Exchange
as a result of which the reported trading prices for stocks then constituting 20% or more of the level of the Index (or the relevant Successor Index) at any time during the one hour period preceding the close of the principal trading session on such
Relevant Exchange are materially inaccurate; 
 (3)    a suspension, absence or material limitation of trading on any
major securities exchange for trading in futures or options contracts or exchange traded funds related to the Index (or the relevant Successor Index) at any time during the one hour period preceding the close of, the principal trading session on
such exchange; or 
 (4)    a decision to permanently discontinue trading in the relevant futures or options contracts
or exchange traded funds; 
 in each case as determined by the Calculation Agent in its sole discretion. 
 For the purpose of determining whether a Market Disruption Event exists at any time, if trading in a security included in the Index (or the relative
Successor Index) is materially suspended or materially limited at that time, then the relevant percentage contribution of that security to the level of the Index (or the relative Successor Index) shall be based on a comparison of: 
 (1)    the portion of the level of the Index attributable to that security relative to 
 (2)    the overall level of the Index (or the relative Successor Index), 
 in each case immediately before that suspension or limitation. 
 For purposes of determining whether a Market Disruption Event has occurred: 
 (1)    a limitation on the hours
or number of days of trading will not constitute a Market Disruption Event if it results from an announced change in the regular business hours of the Relevant Exchange or market; 
 (2)    limitations pursuant to the rules of any Relevant Exchange similar to NYSE Rule 80B (or any applicable rule or regulation
enacted or promulgated by any other self-regulatory organization or any government agency of scope similar to NYSE Rule 80B as determined by the Calculation Agent in its sole discretion) on trading during significant market fluctuations will
constitute a suspension, absence or material limitation of trading; 
 (3)    a suspension of trading in futures or
options contracts on the Index by the primary securities market trading in such contracts by reason of (i) a price change exceeding limits set by such exchange or market, (ii) an imbalance of orders relating to such contracts, or
(iii) a disparity in bid and ask quotes relating to such contracts, will, in each such case, constitute 

  

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a suspension, absence or material limitation of trading in futures or options contracts related to the Index; and 
 (4)    a suspension, absence or material limitation of trading on any Relevant Exchange or on the primary market on which futures or
options contracts related to the Index (or the relative Successor Index) are traded will not include any time when such market is itself closed for trading under ordinary circumstances. 
 “Maturity Date” shall mean August 29, 2008, unless that day is not a Business Day, in which case the amount equal to the Payment
at Maturity that would otherwise be due on the scheduled Maturity Date will instead be due on the next succeeding Business Day following such scheduled Maturity Date, with the same effect as if paid on the scheduled Maturity Date; provided that if
due to a non-Trading Day or a Market Disruption Event, the Final Valuation Date is postponed so that it falls less than five Business Days prior to the scheduled Maturity Date, the Maturity Date will be the fifth Business Day following the Final
Valuation Date, as postponed. 
 “Maximum Gain” shall be 25.90%. 
 “NYSE” shall mean The New York Stock Exchange, Inc. 
 “Payment at Maturity”, as calculated by the Calculation Agent, for each $10 principal amount Security shall equal: 
  

	 	•	 	 If the Index Return is less than 0% and the absolute value of the Index Return multiplied by the Leverage Factor exceeds the Maximum Gain, $10 + ($10 ×
Maximum Gain). 


  

	 	•	 	 If the Index Return is less than 0% and the absolute value of the Index Return multiplied by the Leverage Factor is equal to or below the Maximum Gain, $10 +
($10 × absolute value of Index Return × Leverage Factor). 


  

	 	•	 	 If the Index Return is (i) greater than or equal to 0% and (ii) equal to or below the Downside Protection Level, $10. 


  

	 	•	 	 If the Index Return is above the Downside Protection Level, $10 – ($10 × (Index Return – Downside Protection Level)); provided, however, that
the Payment at Maturity for each $10 principal amount Security will never be less then the $10 × Principal Protection at Maturity. 


 provided, however, that in no event shall the Holder owe any amount to the Company. 
 “Place of Payment”
shall mean the place or places where the Payment at Maturity on the Securities is payable. 
 “Principal Protection at
Maturity” shall equal 10%. 
  

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 “Relevant Exchange” for any security (or any combination thereof) then included in the
Index or any Successor Index, means the primary exchange, quotation system (which includes bulletin board services) or other market of trading for such security. 
 “Securities” shall have the meaning set forth on the reverse of this Security. 
 “Security” shall have the meaning set forth on the face of this Security. 
 “Successor Index”
shall have the meaning specified under “Discontinuation of the Index; Alteration of Method of Calculation.” 
 “Trade
Date” shall mean June 26, 2007. 
 “Trading Day” means a day, as determined by the Calculation Agent, on
which trading is generally conducted on (i) the Relevant Exchanges for securities included in the Index (or the relevant Successor Index) and (ii) the exchanges on which futures or options contracts related to the Index (or the relevant
Successor Index) are traded, other than a day on which trading is scheduled to close prior to its scheduled weekday closing time. 
 “Trustee” shall have the meaning set forth on the reverse of this Security. 
 All terms used but not defined in
this Security are used herein as defined in the Calculation Agency Agreement or the Indenture. 
 Calculation Agent 
 The Calculation Agent will determine, among other things, the Index Closing Level on the Final Valuation Date, including the Index Return and the Index
Ending Level and the Payment at Maturity, on the Securities. In addition, the Calculation Agent will determine whether there has been a Market Disruption Event or a discontinuation of the Index (or the relevant Successor Index) and whether there has
been a material change in the method of calculating the Index. All calculations, determinations and adjustments made by the Calculation Agent will be at the sole discretion of the Calculation Agent and will, in the absence of manifest error, be
conclusive for all purposes and binding on Holders and on the Company. The Company may appoint a different Calculation Agent from time to time after the date of the original issue of the Securities without Holders’ consent and without notifying
Holders. 
 Discontinuation of the Index; Alteration of Method of Calculation 
 Dow Jones Industrial AverageSM 
 If Dow Jones & Company, Inc.
discontinues publication of the Dow Jones Industrial AverageSM and Dow Jones & Company, Inc. or another
entity publishes a successor or substitute index that the Calculation Agent determines, in its sole discretion, to be comparable to the discontinued Dow Jones Industrial AverageSM (such index being referred to herein as a “Successor Index”), then any Index Closing Level will be determined by reference to the level of such
Successor Index at the close of trading on the Relevant Exchange or market for the Successor Index on the Final Valuation Date. 
  

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 Upon any selection by the Calculation Agent of a Successor Index, the Calculation Agent will cause
written notice thereof to be promptly furnished to the Trustee, to the Company and to the Holders. 
 If Dow Jones & Company, Inc.
discontinues publication of the Dow Jones Industrial AverageSM prior to, and such discontinuation is continuing on,
the Final Valuation Date and the Calculation Agent determines, in its sole discretion, that no Successor Index is available at such time, or the Calculation Agent has previously selected a Successor Index and publication of such Successor Index is
discontinued prior to, and such discontinuation is continuing on, the Final Valuation Date, or if Dow Jones & Company, Inc. (or the publisher of any Successor Index) fails to calculate and publish a Closing Level for the Dow Jones
Industrial AverageSM (or any Successor Index) on any date when it would ordinarily do so in accordance with its
customary practice, then the Calculation Agent will determine the Index Closing Level for such date. The Index Closing Level will be computed by the Calculation Agent in accordance with the formula for and method of calculating the Dow Jones
Industrial AverageSM or Successor Index, as applicable, last in effect prior to such discontinuation or failure to
calculate or publish a Closing Level for the Dow Jones Industrial AverageSM or Successor Index, as applicable, using
the Closing Price (or, if trading in the relevant securities has been materially suspended or materially limited, its good faith estimate of the Closing Price that would have prevailed but for such suspension or limitation) at the close of the
principal trading session on such date of each security most recently included in the Dow Jones Industrial AverageSM
or Successor Index, as applicable. 
 If at any time the method of calculating the Dow Jones Industrial AverageSM or Successor Index, or the level thereof, is changed in a material respect, or if the Dow Jones Industrial AverageSM or a Successor Index is in any other way modified so that the Dow Jones Industrial AverageSM or such Successor Index does not, in the opinion of the Calculation Agent, fairly represent the level of the Dow Jones Industrial AverageSM or such Successor Index had such changes or modifications not been made, then the Calculation Agent will, at the close of
business in New York City on each date on which the Dow Jones Industrial AverageSM Closing Level is to be
determined, make such calculations and adjustments as, in the good faith judgment of the Calculation Agent, may be necessary in order to arrive at a level of stock index comparable to the Dow Jones Industrial AverageSM or such Successor Index, as the case may be, as if such changes or modifications had not been made and the Calculation Agent
will calculate the Index Closing Level with reference to the Dow Jones Industrial AverageSM or such Successor Index,
as adjusted. Accordingly, if the method of calculating the Dow Jones Industrial AverageSM or Successor Index is
modified so that the level of the Dow Jones Industrial AverageSM or such Successor Index is a fraction of what it
would have been if there had been no such modification (e.g., due to a split in the Dow Jones Industrial AverageSM),
then the Calculation Agent will adjust its calculation of the Dow Jones Industrial AverageSM or such Successor Index
in order to arrive at a level of the Dow Jones Industrial AverageSM or such Successor Index as if there had been no
such modification (e.g., as if such split had not occurred). 
  

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 The following abbreviations, when used in the inscription on the face of the within Security, shall be
construed as though they were written out in full according to applicable laws or regulations: 
  

							
	TEN COM -	    	as tenants in common	    	UNIF GIFT MIN ACT - _________ Custodian  _________
		    		    	                          (Cust)             
     (Minor)

	TEN ENT -	    	as tenants by the entireties	    	under Uniform Gifts to Minors
	JT TEN -	    	as joint tenants with right of	    	Act	  	  

		    	Survivorship and not as tenants in common	    		  	(State)

 Additional abbreviations may also be used though not in the above list. 
                                       
                   
 FOR VALUE RECEIVED, the
undersigned hereby sells, assigns and transfers unto 
 PLEASE INSERT SOCIAL SECURITY OR OTHER 
 IDENTIFYING NUMBER OF ASSIGNEE 
  

			
	  	 	 
	  	 	 

  
  
  

	
	 

 (Name and Address of Assignee, including zip code, must be printed or typewritten.) 
  

	
	  

 the within Security, and all rights thereunder, hereby irrevocably constituting and appointing 
  

	
	 

 to transfer the said Security on the books of the Company, with full power of substitution in the premises.

 Dated: 
 __________________________________________ 
 NOTICE: The signature to this assignment must correspond with the name as it appears
upon the face of the within Security in every particular, without alteration or enlargement or any change whatever. 
 Signature(s) Guaranteed: 

__________________________ 
 THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN
ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED MEDALLION SIGNATURE GUARANTEE PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15. 
  

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