EX-10.49






Exhibit 10.49




The Goldman Sachs Group, Inc.

Signature Card For ____ Year-End Awards and the BNY Mellon Custody Account 

and Consent to Receive Electronic Delivery 







IMPORTANT: PLEASE REVIEW, EXECUTE AND RETURN THIS FORM TO: EQUITY COMPENSATION

(DIVISION OF HCM), 30 HUDSON STREET, 35TH FLOOR, JERSEY CITY, NJ
07302.


YOU MUST PROPERLY EXECUTE THIS FORM TO ACKNOWLEDGE ACCEPTANCE OF THE
TERMS AND 
CONDITIONS OF YOUR AWARD(S) AND RELATED MATTERS.


 



1. I have received and agree to be bound by The Goldman Sachs Amended and Restated Stock
Incentive Plan (the “SIP”) and the Award Agreement(s) applicable to me in connection with the ___
Year-End Award(s) (the “Award(s)”) that I have been granted by the Firm (as defined below). I
confirm that I have accepted the Award(s) subject to the terms and conditions contained in the SIP
and the Award 
Agreement(s), including but not limited to, the requirement that disputes relating to
the Award(s) and the Award Agreement(s) be decided through arbitration in New York City and be
governed by New York law.



As a condition of this grant, I understand that the Award(s) (as well as any other award that the
Firm may grant to me under the SIP) is/are subject to other governing law provisions (as outlined
in this signature card, in the current or otherwise then current Award Summary (as defined below)
or otherwise as may be required under applicable law) and, as a condition to receiving such awards,
I agree to be bound thereby. I also understand that the Firm may grant to me other awards under the
SIP that also may contain (among other terms and conditions) arbitration and other governing law
provisions and, as a condition to receiving such awards, I agree to be bound thereby. As a
condition of this grant, I agree to provide upon request an appropriate certification regarding my
U.S. tax status on Form W-8BEN, Form W-9, or other appropriate form, and I understand that failure
to supply a required form may result in the imposition of backup withholding on certain payments I
receive pursuant to this grant.



Further, as a condition of this grant, if I am a person who has worked in the United
Kingdom at any time during the earnings period relating to any award under the SIP, as
determined by the Firm, when requested and as directed by the Firm, I will agree to a Joint
Election under s431 ITEPA 2003 of the laws of the United Kingdom for full or partial disapplication
of Chapter 2 Income Tax (Earnings and Pension) Act 2003 under the laws of the United Kingdom and
will sign and return such election in respect of all future deliveries of shares underlying the
Award(s) and any previous grants made to me under the SIP and understand that the Firm intends to
meet its delivery obligations in shares with respect to my Award(s), except as may be prohibited by
law or described in the accompanying Award Agreement or supplementary materials.



If I have worked in Switzerland at any time during the earnings period relating to the
Award(s) granted to me as determined by the Firm, (i) I acknowledge that my Award(s) are subject to
tax in accordance with the rulings and method of calculation of taxable values to be agreed by the
Firm with the Federal and/or Zurich/Geneva cantonal/communal tax authorities or as otherwise
directed by the Firm, and (ii) I hereby agree to be bound by any rulings agreed by the Firm in
respect of any Award(s), which is expected to result in taxation at the time of delivery of shares
(or cash or other property in lieu thereof), and (iii) I undertake to declare and make a full and
accurate income tax declaration in respect of my Award(s) in accordance with the above ruling or as
directed by the Firm.



I understand and acknowledge that any transfer provisions (including, where applicable, escrow and
other similar provisions, but specifically excluding any transfer restrictions imposed on any
Award(s) in the Award Agreement(s) or the SIP) in the SIP or related documents will not apply to me
(i) to the extent that the applicability of those provisions would affect the availability of
relevant exemptions or tax favorable treatment, or (ii) otherwise in circumstances determined by
the Firm in its sole discretion.



2. I have read and understand the Firm’s “Notice Periods for Recipients of Year-End Equity-Based
Awards” (the “Notice Policy”), pursuant to which I am required to provide certain specified advance
notice of my intent to leave employment with the Firm. I understand that in executing this form, I
will be agreeing to provide my employing entity with advance notice of my intention to leave
employment with the Firm as follows:




	 	•	 	In the Americas, Japan and Asia Ex-Japan (excluding India): 60 days in advance of my
termination date
	 
	 	•	 	In Europe, the Middle East, Africa and India: 90 days in advance of my termination date





and that, where applicable (see the provisions in the Award Summary), the provisions of the Notice
Policy constitute a permanent change to my terms and conditions of employment. I agree to this
change in consideration of my continued employment with the Firm and my acceptance of the Award(s),
and I agree to be bound by the Notice Policy as in effect from time-to-time.



I also understand that the terms and conditions of my employment shall be permanently changed so
that, in the event that I resign from the Firm, the Firm may either:




	 	•	 	Unilaterally waive or reduce the notice period otherwise applicable to my employment, or
	 
	 	•	 	Take such other action as shall have that effect.





I acknowledge that the Firm retains its right to bring forward the end of the notice period to such
earlier date, and that I will not be entitled to any salary, wages, or benefits after such earlier
date. In addition, I understand that I will not receive pay in lieu for any period of notice that
has been waived or reduced.



This agreement concerning my notice period is being made for and on behalf of my Goldman Sachs
employing entity, and implementation of the Notice Policy does not create an employment
relationship between me and The Goldman Sachs Group, Inc.



I understand that unless the notice period is waived by agreement or unilaterally as set out above,
or I have exercised a statutory right to make a payment in lieu of my notice period, I will be paid
my base salary and will continue to receive all mandatory benefits during the notice period. I
understand that during my notice period I may (subject to any local laws to the contrary) be
required to remain away from the Firm’s offices, and/or be removed from any assigned duties or
assigned to other suitable duties during my notice period.



I understand that if I fail to give the full amount of notice as set out above, or to comply in any
respect with the Notice Policy, I will have failed to meet an obligation I have under an agreement
with the Firm, as a result of which the Firm may have certain rights and I may be subject to
certain legal and equitable rights and remedies, including, without limitation, the forfeiture of
the Award(s) and any other awards granted to me (whether before or after the Award(s)) under the
SIP. The forfeiture of such Award(s) will also apply where I fail to give the full amount of notice
by exercising any right I may have under applicable legislation to make a payment in lieu of such
notice. I also understand that, if I fail to comply with the Notice Policy, the Firm may be
entitled to an injunction from a court restraining me from violating it.



I understand that, for employees of Archon Group, L.P., the Notice Policy applies only to Senior
Executives.



3. I have read and understand the Firm’s hedging and pledging policies (including, without
limitation, the Firm’s “Policies With Respect to Transactions Involving GS Shares, Equity Awards
and GS Options by Persons Affiliated with GS Inc.”), and agree to be bound by them (with respect to
the Award(s) and any prior awards under the SIP), both during and following my employment with the
Firm.



4. If a custody account is required, I request that The Bank of New
York Mellon (“BNY Mellon”) (successor in interest to Mellon Bank, N.A.)  open a custody account for
me as described in the enclosed Custody Agreement among BNY Mellon (as successor in interest to
Mellon Bank N.A.), The Goldman Sachs Group, Inc., and myself. I have received and agree to be bound
by the Custody Agreement (or any other such custody agreement previously entered into by me or on
my behalf), including the applicable restrictions on transfers, pledges and withdrawals of Common
Stock, the provisions permitting the Firm to monitor my custody account, and the limitations on the
liability of BNY Mellon and the Firm. I also agree to open an account with any other custodian or
broker selected by the Firm, if the Firm, in its sole discretion, requires me to open an account
with such custodian or broker as a condition to delivery of shares (or cash or other property)
underlying the Award(s).



5. If the Firm advanced or loaned me funds to pay certain taxes (including income taxes and Social
Security, or similar contributions) in connection with the Award(s) (or does so in the future), and
if I have not signed a separate loan agreement governing repayment, I authorize the Firm to
withhold from my compensation any amounts required to reimburse it for any such advance or loan to
the extent permitted by applicable law.



I understand and agree that, if I leave the Firm, I am required immediately to repay any
outstanding amount. I further understand and agree that the Firm has the right to offset, to the
extent permitted by the Award Agreement and applicable law (including Section 409A of the U.S.
Internal Revenue Code of 1986, as amended, which limits the
Firm’s ability to offset in the case of United States taxpayers under certain circumstances), any
outstanding amounts that I then owe the Firm against its delivery obligations under the Award(s) or
against any other amounts the Firm then owes me. I understand that the delivery of shares pursuant
to the Award(s) is conditioned on my satisfaction of any applicable taxes or social security
contributions (collectively referred to as “tax” or “taxes” for purposes of the SIP and all related
documents) in accordance with the SIP. To the extent permitted by applicable law, the Firm, in its
sole discretion, may require me to provide amounts equal to all or a portion of any Federal, State,
local, foreign or other tax obligations imposed on me or the Firm in connection with the grant,
vesting or delivery of the Award(s) by requiring me to choose







Year End
(General)



 









 






between remitting such amount (i) in
cash (or through payroll deduction or otherwise) or (ii) in the form of proceeds from the Firm’s
executing a sale of shares delivered to me pursuant to the Award(s). However, in no event shall any
such choice or the choice specified in paragraph 6, below, determine, or give me any discretion to
affect, the timing of the delivery of shares or payment of tax obligations. I understand and agree
that the Firm may reduce any year-end cash bonus that I may receive by an amount equal to the
estimated Indian Fringe Benefit Tax applicable to any award (whether or not vested), as determined
by the Firm in its sole discretion.



6. If I am an individual with separate employment contracts (at any time during and/or after the
Firm’s ___fiscal year), I acknowledge and agree that the Firm may, in its sole discretion,
require (to the extent permitted by applicable law) that I provide for a reserve in an amount the
Firm determines is advisable or necessary in connection with any actual, anticipated or potential
tax consequences related to my separate employment contracts by requiring me to choose between
remitting such amount (i) in cash (or through payroll deductions or otherwise) or (ii) in the form
of proceeds from the Firm’s executing a sale of shares delivered to me pursuant to the Award(s) (or
any other of my awards outstanding under the SIP).



7. In connection with any Award Agreement or other interest I may receive in the SIP or any shares
of Common Stock of The Goldman Sachs Group, Inc. that I may receive in connection with the Award(s)
or any award I have previously received or may receive, or in connection with any amendment or
variation thereof or any documents listed in paragraph 8, I hereby consent to (a) the acceptance by
me of the Award(s) electronically, (b) the giving of instructions in electronic form whether by me
or the Firm, and (c) the receipt in electronic form at my email address maintained at Goldman Sachs
or via Goldman Sachs’ intranet site (or, if I am no longer employed by the Firm, at such other
email address as I may specify, or via such other electronic means as the Firm and I may agree) all
notices and information that the Firm is required by law to send to me in connection therewith
including, without limitation, any document (or part thereof) constituting part of a prospectus
covering securities that have been registered under the U.S. Securities Act of 1933, the
information contained in any such document and any information required to be delivered to me under
Rule 428 of the U.S. Securities Act of 1933, including, for example, the annual report to security
holders or the annual report on Form 10-K of The Goldman Sachs Group, Inc. for its latest fiscal
year, and that all prior elections that I may have made relating to the delivery of any such
document in physical form are hereby revoked and superseded. I agree to check Goldman Sachs’
intranet site (or, if I am no longer employed by the Firm, such other electronic site as the Firm
and I may agree) periodically as I deem appropriate for any new notices or information concerning
the SIP. I understand that I am not required to consent to the receipt of such documents in
electronic form in order to receive the Award(s) and that I may decline to receive such documents
in electronic form by contacting Equity Compensation (division of HCM), 30 Hudson Street, 35th
Floor, Jersey City, NJ 07302, telephone (212) 357-1444, which will provide me with hard copies of
such documents upon request. I also understand that this consent is voluntary and may be revoked at
any time on three business days’ written notice.



8. I hereby acknowledge that I have received in electronic form in accordance with my consent in
paragraph 7 the following documents:




	 	•	 	The Goldman Sachs Amended and Restated Stock Incentive Plan;
	 
	 	•	 	Summary of The Goldman Sachs Amended and Restated Stock Incentive Plan;
	 
	 	•	 	Custody Agreement with BNY Mellon;
	 
	 	•	 	The ___Annual Report for The Goldman Sachs Group, Inc.;
	 
	 	•	 	The annual report on Form 10-K for The Goldman Sachs Group, Inc. for the fiscal year
ended ___, filed with the Securities Exchange Commission on ___;
	 
	 	•	 	The Award Agreement(s); and
	 
	 	•	 	Summaries of the Award(s) (“Award Summary”).





9. I expressly authorize any appropriate representative of the Firm to make any notifications,
filings or remittances of funds that may be required in connection with the SIP or otherwise on my
behalf. Further, if I am an employee who is resident in South Africa at the time of share
acquisition, by accepting my Award(s), I expressly authorize any appropriate representative of the
Firm to make any required notification on my behalf to the Reserve Bank of South Africa (or its
authorized dealer) in relation to any acquisition of shares for no consideration under the SIP or
other similar filing that may otherwise be required in South Africa. I acknowledge that any such
authorization is effective from the date of acceptance of my Award(s) until such time as I
expressly revoke the authorization by written notice to any appropriate representative of the Firm.
I understand that this authorization does not create any obligation on the Firm to deal with any
such notifications, filings or remittances of funds that I may be required to make in connection
with the SIP and I accept full responsibility in this regard.



Consent to Data Collection, Processing and Transfers:






I understand and agree that in connection with the SIP and any other Firm benefit plan (the
“Programs”), to the extent permitted under the laws of the applicable jurisdiction, the Firm may
collect and process various data that is personal to me, including my name, address, work location,
hire date, Social Security or Social Insurance or taxpayer identification number (required for tax
purposes), type and amount of SIP or other benefit plan award, citizenship or residency (required
for tax purposes) and other similar information reasonably necessary for the administration of such
Programs (collectively referred to as “Information”) and provide such Information to its affiliates
and BNY Mellon (and its affiliates) or any other service provider, whether in the United States or
elsewhere, as is reasonably necessary for the administration of the Programs and under the laws of
these jurisdictions. I understand that, in certain circumstances, foreign courts, law enforcement
agencies or regulatory agencies may be entitled to access the Information. I understand that,
unless I explicitly authorize otherwise, the Firm, its affiliates and its service providers
(through their respective employees in charge of the relevant electronic and manual processing)
will use this Information only for purposes of administering the Programs. I understand that, in
the United States and in other countries to which such Information may be transferred for the
administration of the Programs, the level of data protection is not equivalent to data protection
standards in the member states of the European Union. I understand that, upon request, to Equity
Compensation (division of HCM), 30 Hudson Street, 35th Floor, Jersey City, NJ 07302, telephone
(212) 357-1444, to the extent required under the laws of the applicable jurisdiction, I may have
access to and obtain communication of the Information and may exercise any of my rights in respect
of such Information, including objecting to the processing of the Information and requesting that
the Information be corrected (if wrong), completed or clarified (if incomplete or equivocal), or
erased (if cannot legally be collected or kept). Upon request, to the extent required under the
laws of the applicable jurisdiction, Equity Compensation (division of HCM) will also provide me,
free of charge, with a list of all the service providers used in connection with the Programs at
the time of request. I understand that, if I refuse to authorize the use and transfer of the
Information consistent with the above, I may not benefit from the Programs. I authorize the use and
transfer of the Information consistent with the above for the period of administration of the
Programs. In particular, I authorize (within the limits described above): (i) the data processing
by the Firm (which means The Goldman Sachs Group, Inc. and its subsidiaries and affiliates); (ii)
the data processing by BNY Mellon and its affiliates; (iii) the data processing by the Firm’s other
service providers; and (iv) the data transfer to the United States and other countries. I further
acknowledge that the Information may be retained by such persons beyond the period of
administration of the Programs to the extent permitted under the laws of the applicable
jurisdiction and I so authorize.






Other Legal Notices:




FOR ARGENTINA EMPLOYEES ONLY




This is a private offer. It is not subject to the supervision of the Comision Nacional de Valores
(CNV) or any other governmental authority in Argentina.



FOR AUSTRALIA EMPLOYEES ONLY




“This document is provided for your information only. This document does not constitute an offer of
securities. Your individual offer of participation will be given to you directly with a printed
copy of the disclosure document.”



FOR BRAZIL EMPLOYEES ONLY




Please note that the offer of an award under the SIP does not constitute a public offer in Brazil,
and therefore it is not subject to registration with the Brazilian authorities.



According to Brazilian regulations, individuals resident in Brazil must inform the Central Bank of
Brazil yearly the amounts of any nature, the assets and rights (including cash and other deposits)
held outside of the Brazilian territory. Please consult your own legal counsel on the terms and
conditions for presentation of such information.



By accepting the Award(s), you acknowledge that the Firm has provided you with Portuguese
translations of the Award Summary, Award Agreement and Signature Card, but that the original
English version of these documents controls. (Ao aceitar esta outorga, Você reconhece que a Empresa
Ihe disponibilizou a versão em português do Award Summary, do Award Agreement e do Signature Card;
porém a versão original em inglês desses documentos prevalecerá.)



FOR CANADA EMPLOYEES IN QUEBEC ONLY




By accepting the Award(s), you acknowledge and agree that you and the Firm expressly wish that all
documents related to the Award(s) (including, without limitation, the Plan document, this Signature
Card, the Award Agreement and the Award Summary) be in English.



FOR THE PEOPLE’S REPUBLIC OF CHINA EMPLOYEES ONLY




All documentation in relation to the Award(s) is intended for your personal use and in your
capacity as an employee of the Firm (and/or its affiliate) and is being given to you solely for the
purpose of providing you with information concerning




Year End
(General)



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the Award(s) which the Firm may grant to you
as an employee of the Firm (and/or its affiliate) in accordance with the terms of the SIP, this
documentation and the applicable Award Agreement(s). The grant of the Award(s) has not been and
will not be registered with the China Securities Regulatory Commission of the People’s Republic of
China pursuant to relevant securities laws and regulations, and the Award(s) may not be offered or
sold within the mainland of the People’s Republic of China by means of any of the documentation in
relation to the Award(s) through a public offering or in circumstances which require a registration
or approval of the China Securities Regulatory Commission of the People’s Republic of China in
accordance with the relevant securities laws and regulations.



FOR FRANCE EMPLOYEES ONLY




Disclaimer: The current award is not covered by any prospectus which is the subject of the AMF’s
approval. Grantees can only receive this award for their own account (“compte propre”) in the
conditions laid down by articles D. 411-1, D. 411-2, D.411-3, D.411-4, D. 734-1, D. 744-1, D. 754-1
and D. 764-1 of the French Monetary and Financial Code. Any direct or indirect dissemination into
the public of the financial instruments acquired can only take place within the conditions of
articles L. 411-1, L. 411-2, L. 412-1 and L. 621-8 to L. 621-8-3 of the French Monetary and
Financial Code.



By accepting this award, you acknowledge that the Firm has provided you with French translations of
the Award Summary, Award Agreement and Signature Card, but that the original English version of
these documents control.



Avertissement: La présente attribution ne donne pas lieu à un prospectus soumis au visa de
l’Autorité des marches financiers. Les personnes qui y participent ne peuvent le faire que pour
compte propre dans les conditions fixées par les articles D.
411-1, D. 411-2, D.411-3, D.411-4, D.734-1, D. 744-1, D. 754-1 et D. 764-1 du Code monetaire et financier. La diffusion, directe ou
indirecte, dans le public des instruments financiers ainsi acquis, ne peut être réalisée que dans
les conditions prévues aux articles L. 411-1, L. 411-2 L. 412-1 et L. 621-8 à L. 621-8-3 du Code
monétaire et financier.



En acceptant cet octroi, vous reconnaissez que la Société vous á transmis une version français de
l’Award Summary (Résumé de l’Octroi), l’Award Agreement (Contrat d’Octroi) et de la Signature Card
(Carte de Signature), mais que seule la version originale en langue anglaise fait foi.”



FOR GERMANY EMPLOYEES ONLY




The
Award(s) are offered to you by The Goldman Sachs Group, Inc. (“GS Inc.”) in accordance with the
terms of the SIP which are summarized in the Award Summary. More information about GS Inc. is
available on www.gs.com. You are being offered Award(s) under the SIP in order to provide an
additional incentive and to encourage employee share ownership and so increase your interest in the
Firm’s success. Please refer to the section entitled Shares Available for Awards in the SIP for
information on the maximum number of GS Inc. shares that can be offered under the SIP. The
obligation to publish a prospectus under the Prospectus Directive does not apply to the offer
because of Article 4(1)(e) of that directive.



“Die
Prämien werden lhnen von der The Goldman Sachs Group, Inc. (,,GS Inc.”) gemäß den in der
Prämienübersicht aufgeführten Bestimmungen des Erwerbsplans angeboten. Weitere Informationen über
GS Inc. finden Sie unter www.gs.com. Die Prämien werden lhnen im Rahmen des Erwerbsplans angeboten,
um einen zusätzlichen Anreiz darzustellen und Sie als Mitarbeiter zum Erwerb von Aktien zu
ermutigen, um so Ihren Anteil am Erfolg des Unternehmens zu vergrößern. Informationen zur Anzahl
der im Rahmen des Plans angebotenen GS Inc.-Aktien entnehmen Sie bitte dem Abschnitt als Prämien
erhältliche Aktien im Erwerbsplan. Die Verpflichtung zur Veröffentlichung eines Emissionsprospekts
gemäß der europäischen Prospektrichtlinie trifft auf Grund von Artikel 4(1)(e) dieser Richtlinie
nicht auf dieses Angebot zu.”



FOR HONG KONG EMPLOYEES ONLY




WARNING:



The contents of this document have not been reviewed by any regulatory authority in Hong Kong. You
are advised to exercise caution in relation to the offer. If you are in doubt about any of the
contents of this document, you should obtain independent professional advice.



By accepting the Award(s), you acknowledge and accept that you will not be permitted to transfer
awards to persons who fall outside the definition of ‘qualifying persons’ in the Companies
Ordinance (i.e., a person who is not a current or former director, employee, officer, consultant of
the Firm or a person other than the offeree’s wife, husband, widow, widower, child or step-child
under the age of 18 years, or as otherwise defined), even if otherwise permitted under the SIP or
any of the related documents.



FOR INDIA EMPLOYEES ONLY




This website does not invite offers from the public for subscription or purchase of the securities
of any body corporate under any law for the time being in force in India. The website is not a
prospectus under the applicable laws for the time being in force in India. Goldman Sachs does not
intend to market, promote, invite offers for subscription or purchase of the securities of any body
corporate by this website. The information provided on this website is for the record only. Any
person who subscribes or purchases securities of any body corporate should consult his own
investment advisers before making any investments. Goldman Sachs shall not be liable or responsible
for any such investment decision made by any person.



FOR MONACO EMPLOYEES ONLY




By accepting your Award(s), you expressly renounce the jurisdiction of Monaco (and, if applicable,
France and notably the application of articles 14 and 15 of the French Civil Code) in connection
with any dispute relating to your Award(s).



FOR RUSSIA EMPLOYEES ONLY




None of the information contained in the documents referred to in paragraph 8 of this signature
card or in this signature card constitutes an advertisement of the Award(s) in Russia and must not
be passed on to third parties or otherwise be made publicly available in Russia. The Award(s) have
not been and will not be registered in Russia and are not intended for “placement” or “public
circulation” in Russia.



FOR SWEDEN EMPLOYEES ONLY




By accepting the Award(s), you acknowledge and accept that any transfer provisions (including,
where applicable, escrow and other similar provisions) in the SIP or any related documents do not
apply to you.



FOR UK EMPLOYEES ONLY




This document is approved by Goldman Sachs International (“GSI”), Peterborough Court, 133 Fleet
Street, London EC4A 2BB, which is authorized and regulated by the Financial Services Authority. The
document relates to investments and investment services of The Goldman Sachs Group Inc. and other
institutions, including BNY Mellon, relating to custodial and delivery operations. In some or all
respects, the regulatory system applying to these entities, including any compensation arrangements
and rules made under the Financial Services and Markets Act 2000 for the protection of private
customers, will be different from that of the United Kingdom.



This document does not have regard to the specific investment objectives, financial situation and
particular needs of any specific person who may receive it. Recipients should seek their own
financial advice.



The Award(s) is/are subject to the terms and conditions set forth in the SIP and the Award
Agreement. The price of shares and the income from such shares (if any) can fluctuate and may be
affected by changes in the exchange rate for U.S. Dollars. Past performance will not necessarily be
repeated. Levels and bases of taxation may change from time to time. Investors should consult their
own tax advisers in order to understand tax consequences. The Goldman Sachs Group, Inc. has (and
its associates, including GSI, may have) a material interest in the shares and the investments that
are the subject of this document.



	 	 	 	 	 	 	 
	Signature

	 	 	 	Date:	 	 
	 

	 	 
	 	 	 	 
	 
	Print Name:

	 	 	 	Employee ID #:	 	 
	 

	 	 
	 	 	 	 





Year End
(General)


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