Document:

EX-4.7.4

 Exhibit 4.7.4 

UNLESS THIS NOTE IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY TRUST COMPANY TO THE COMPANY OR ITS AGENT FOR REGISTRATION OF TRANSFER,
EXCHANGE OR PAYMENT AND ANY NOTE ISSUED IS REGISTERED IN THE NAME OF CEDE & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY TRUST COMPANY OR SUCH OTHER REPRESENTATIVE OF THE DEPOSITORY TRUST
COMPANY OR SUCH OTHER NAME AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPOSITORY TRUST COMPANY (AND ANY PAYMENT HEREON IS MADE TO CEDE & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF THE
DEPOSITORY TRUST COMPANY), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL SINCE THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN INTEREST HEREIN. 

TRANSFERS OF THIS GLOBAL NOTE SHALL BE LIMITED TO TRANSFERS IN WHOLE, BUT NOT IN PART, TO NOMINEES OF CEDE & CO. OR TO A SUCCESSOR THEREOF OR SUCH
SUCCESSOR’S NOMINEE. 
  

	 REGISTERED 
	 REGISTERED 

[FACE OF NOTE] 
 Kansas City
Southern de México, S.A. de C.V. 
 Floating Rate Senior Notes due 2016 

[CUSIP] [                    ] 

[ISIN] [                    ] 

 

	 No. 
	 U.S.$250,000,000 

Kansas City Southern de México, S.A. de C.V., a sociedad anónima de capital variable organized under the laws of Mexico
(the “Company,” which term includes any successor under the Indenture hereinafter referred to), for value received, promises to pay to Cede & Co., or its registered assigns, the principal sum of TWO HUNDRED FIFTY MILLION
DOLLARS or such greater or lesser amount set forth on the Schedule of Exchange of Interests in the Global Note attached hereto on October 28, 2016, subject to the Business Day Convention. 

Interest Payment Dates: January 28, April 28, July 28 and October 28, subject to the Business Day Convention.

  
 1 

 Regular Record Dates: the close of business on the fifteenth calendar day prior to each Interest
Payment Date, whether or not such day is a New York Business Day. 
 Reference is hereby made to the further provisions of this Note set
forth on the reverse hereof, which further provisions shall for all purposes have the same effect as if set forth at this place. 

  
 2 

 IN WITNESS WHEREOF, the Company has caused this Note to be signed manually or by facsimile by its
duly authorized officers. 
  

					
	Date:                    , 2013	 	Kansas City Southern de México, S.A. de C.V.
			
		 	By:	 	  

		 		 	Name:
		 		 	Title:
			
		 	By:	 	  

	 		 	Name:
		 		 	Title:

  
 3 

 Trustee’s Certificate of Authentication 

This is one of the Floating Rate Senior Notes described in the within-mentioned Indenture. 

 

			
	U.S. Bank National Association, as Trustee
		
	By:	 	  

		 	Name:
		 	Title:

  
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 [REVERSE SIDE OF NOTE] 

Kansas City Southern de México, S.A. de C.V. 

Floating Rate Senior Notes 
  

	1.	Principal and Interest. 

 The Company will pay the principal of this Note on
October 28, 2016, subject to the Business Day Convention. 
 The Company promises to pay interest quarterly in arrears on
January 28, April 28, July 28 and October 28 of each calendar year (each, an “Interest Payment Date”), commencing on January 28, 2014, subject to the Business Day Convention. 

Interest payable on any Interest Payment Date or the Final Maturity Date shall be the amount accrued from, and including, the immediately
preceding Interest Payment Date in respect of which interest has been paid as set forth in the Indenture (or from and including October 29, 2013, if no interest has been paid as set forth in the Indenture) to, but excluding, such Interest
Payment Date or the Final Maturity Date, as the case may be. 
 The interest rate for the Initial Interest Period shall be 0.93685%.
Thereafter, the interest rate for any Interest Period shall be the three-month U.S. dollar LIBOR, as determined on the applicable Interest Determination Date by the Calculation Agent in accordance with the
provisions of the Indenture, plus 70 basis points. The interest rate for the Notes will be reset quarterly on each Interest Reset Date. 

The Company shall pay interest on overdue principal and premium, if any, and interest on overdue installments of interest, to the extent
lawful, at the rate per annum borne by the Notes to the extent lawful and in accordance with the terms of the Indenture. 
  

	2.	Method of Payment. 

 The Company will pay principal as provided above and interest
(except defaulted interest) on the principal amount of the Notes as provided above on each Interest Payment Date to the Holder of record of the Notes at the close of business on the fifteenth calendar day prior to each Interest Payment Date,
whether or not such day is a New York Business Day, in each case, even if the Note is cancelled on registration of transfer or registration of exchange after such record date; provided that, with respect to the payment of principal, the
Company will not make payment to the Holder unless this Note is surrendered to a Paying Agent. 
 The Company will pay principal, premium,
if any, and, as provided above, interest (and Additional Amounts, if any) in money of the United States that at the time of payment is legal tender for payment of public and private debts. However, the Company may pay principal, premium, if any, and
interest by its check payable in such money. The Company may mail an interest check to a Holder’s registered address (as reflected in the Note Register). 

  
 5 

 If any Interest Payment Date in respect of any Note (other than the Final Maturity Date) is not a
New York Business Day, then such Interest Payment Date will be postponed to the next succeeding New York Business Day unless that New York Business Day is in the next succeeding calendar month, in which case the Interest Payment Date will be the
immediately preceding New York Business Day. If any such Interest Payment Date (other than the Final Maturity Date) is postponed or brought forward as described above, the interest amount will be adjusted accordingly and the Holder will be entitled
to more or less interest, respectively. If the Final Maturity Date in respect of the Notes or any date fixed for redemption of the Notes is not a New York Business Day, the payment of principal and interest will not be made until the next following
New York Business Day, and no further interest will be paid in respect of the delay in such payment. 
  

	3.	Paying Agent and Registrar. 

 Initially, the Trustee will act as authenticating agent,
Paying Agent in New York and Registrar. The Company may appoint or change any authenticating agent, Paying Agent or Registrar without notice. The Company, any Subsidiary of the Company or any Affiliate of any of them may act as Paying Agent,
Registrar or co-Registrar. 
  

	4.	Indenture. 

 The Company issued the Notes under an Indenture dated as of October 29,
2013 (the “Indenture”), between the Company and the U.S. Bank National Association, as trustee (in such capacity, the “Trustee”), transfer agent, principal paying agent (in such capacity, the “Paying
Agent”) and registrar (in such capacity, the “Registrar”). 
 Capitalized terms herein are used as defined in the
Indenture unless otherwise indicated. The terms of the Notes include those stated in the Indenture and those made part of the Indenture by reference to the Trust Indenture Act. The Notes are subject to all such terms, and Holders are referred to the
Indenture and the Trust Indenture Act for a statement of all such terms. To the extent permitted by applicable law, in the event of any inconsistency between the terms of this Note and the terms of the Indenture, the terms of the Indenture shall
control. The Notes are general unsecured obligations of the Company. 
  

	5.	Redemption. 

 The Notes shall not be subject to any mandatory redemption. Except as
provided in Section 6 hereof, the Notes shall not be redeemable at the option of the Company. 
  

	6.	Redemption for Change in Withholding Taxes. 

 (a) The Notes will be subject to
redemption, in whole but not in part, at the Company’s option at any time at a Redemption Price of 100% of their principal amount, plus accrued interest and Additional Amounts owing thereon, if any, to but excluding the Redemption Date, in the
event the Company becomes or would become obligated to pay, on the next date on which any amount would be payable with respect to such Notes, any Additional Amounts in excess of those attributable to a withholding tax rate of 4.9% as a result of a
change in or 

  
 6 

 
amendment to the laws (including any regulations or general rules promulgated thereunder) of Mexico (or any political subdivision or taxing authority thereof or therein), or any change in or
amendment to any official position regarding the application, administration or interpretation of such laws, regulations or general rules, including a holding of a court of competent jurisdiction, which change or amendment is announced or becomes
effective on or after October 24, 2013. The Company shall not, however, have the right to redeem Notes from a Holder pursuant to this Section 6 except to the extent that it is obligated to pay Additional Amounts to such Holder that are
greater than the Additional Amounts that would be payable based on a Mexican withholding tax rate of 4.9%. 
 (b) Prior to the giving of any
notice of redemption for taxation reasons as described in clause (a) of this Section 6, the Company will deliver to the Trustee: 

(i) an Officer’s Certificate stating that the Company is entitled to effect the redemption and setting forth a statement of facts showing
that the conditions precedent to the Company’s right of redemption for taxation reasons have occurred; and 
 (ii) an Opinion of
Counsel of recognized standing to the effect that the Company has or will become obligated to pay such Additional Amounts as a result of such change or amendment. 

Any such notice, after it is delivered to the Trustee, will be irrevocable. 

 

	7.	Partial Redemption. 

 If less than all of the Notes are to be redeemed at any time, the
Trustee shall select the Notes to be redeemed in compliance with the requirements of the principal national securities exchange, if any, on which the Notes are listed or, if the Notes are not listed on a national securities exchange, pro rata, by
lot or by such other method as the Trustee in its sole discretion shall deem to be fair and appropriate; provided that no Notes of U.S.$2,000 in principal amount or less shall be redeemed in part. 

 

	8.	Notice of Redemption. 

 Notice of any redemption pursuant to Section 6 hereof will
be mailed at least 30 days but not more than 60 days before the Redemption Date to each Holder of Notes to be redeemed at his or her last address as it appears in the Note Register. Notes in original denominations larger than U.S.$2,000 may be
redeemed in part. On and after the Redemption Date, interest ceases to accrue and the principal amount shall remain constant (using the principal amount as of the Redemption Date) on Notes or portions of Notes called for redemption, unless the
Company defaults in the payment of the Redemption Price. 
  

	9.	Repurchase upon Change of Control Repurchase Event. 

 Upon the occurrence of any Change
of Control Repurchase Event, each Holder shall have the right to require the repurchase of its Notes by the Company in cash pursuant to the offer described in the Indenture at a purchase price equal to 101% of the principal amount thereof on the
date of repurchase plus accrued interest, if any, and any Additional Amounts to, but excluding, the date of repurchase. 

  
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 A notice of such Change of Control Repurchase Event will be mailed within 30 days after any
Change of Control Repurchase Event occurs or, at the Company’s option, prior to the Change of Control, but after public announcement of such Change of Control, to each Holder of the Notes with a copy to the Trustee. Notes in original
denominations larger than U.S.$2,000 may be sold to the Company in part. On and after the Change of Control Payment Date, interest ceases to accrue on Notes or portions of Notes surrendered for purchase by the Company, unless the Company defaults in
the payment of the repurchase price. 
  

	10.	Denominations; Transfer; Exchange. 

 The Notes are in registered form without coupons in
minimum denominations of U.S.$2,000 of principal amount and multiples of U.S.$1,000 in excess thereof. A Holder may register the transfer or exchange of Notes in accordance with the Indenture. The Registrar may require a Holder, among other things,
to furnish appropriate endorsements and transfer documents and to pay any taxes and fees required by law or permitted by the Indenture. The Registrar need not register the transfer or exchange of any Notes selected for redemption. Also, it need not
register the transfer or exchange of any Notes for a period of 15 days before a selection of Notes to be redeemed is made. 
  

	11.	Persons Deemed Owners. 

 A Holder shall be treated as the owner of a Note for all
purposes. 
  

	12.	Unclaimed Money. 

 If money for the payment of principal, premium, if any, or interest
remains unclaimed for two years, the Trustee and the Paying Agent will pay the money back to the Company at its request. After that, Holders entitled to the money must look to the Company for payment, unless an abandoned property law designates
another Person, and all liability of the Trustee and such Paying Agent with respect to such money shall cease. 
  

	13.	Discharge Prior to Redemption or Maturity. 

 The Company’s obligations pursuant to
the Indenture will be discharged, except for obligations pursuant to certain sections thereof, subject to the terms of the Indenture, upon the payment of all the Notes or upon the irrevocable deposit with the Trustee of U.S. dollars or Government
Securities sufficient to pay when due principal of and interest on the Notes to maturity or redemption, as the case may be. 
  

	14.	Amendment; Supplement; Waiver. 

 Subject to certain exceptions, the Indenture and the
Notes may be amended or supplemented with the consent of the Holders of a majority in principal amount of the Notes then outstanding, and any existing default or compliance with any provision may be waived with the consent of the Holders of a
majority in principal amount of the Notes then outstanding. Without 

  
 8 

 
notice to or the consent of any Holder, the parties thereto may amend or supplement the Indenture and the Notes to, among other things, cure any ambiguity, omission, mistake, defect or
inconsistency and make any change that does not adversely affect the legal rights of any Holder. 
  

	15.	Restrictive Covenants. 

 The Indenture imposes certain limitations on the ability of the
Company, among other things, to create or permit any lien or merge, consolidate or transfer substantially all of its assets. Within 90 days after the end of each fiscal year, the Company must report to the Trustee on compliance with such
limitations. 
  

	16.	Successor Persons. 

 When a successor person or other entity assumes all the obligations
of its predecessor under the Notes and the Indenture in accordance with the terms of the Indenture, the predecessor person will be released from those obligations. 
  

	17.	Defaults and Remedies. 

 The following events constitute “Events of Default”
under the Indenture: (a) default in the payment of principal of (or premium, if any, on) any Note when the same becomes due and payable at maturity, upon acceleration, redemption or otherwise; (b) default in the payment of interest or
Additional Amounts on any Note when the same becomes due and payable and such default continues for a period of 30 days; (c) the Company defaults in the performance of or breaches any other covenant or agreement of the Company in the Indenture
or under this Note (other than a default specified in clause (a) or (b) above), and such default or breach continues for a period of 90 consecutive days after written notice by the Trustee or the Holders of 25% or more in aggregate
principal amount of the Notes; (d) a court having jurisdiction in the premises enters a decree or order for (i) relief in respect of the Company or any of its Significant Subsidiaries in an involuntary case under any applicable bankruptcy,
insolvency or other similar law now or hereafter in effect, (ii) appointment of a receiver, liquidator, assignee, síndico, custodian, trustee, sequestrator or similar official for the Company any of its Significant Subsidiaries or
for all or substantially all of the Company’s property and assets or those of its Significant Subsidiaries or (iii) the winding-up or liquidation of the Company’s affairs or the affairs of any of its Significant Subsidiaries and, in
each case, such decree or order shall remain unstayed and in effect for a period of 30 consecutive days; (e) the Company or any of its Significant Subsidiaries (i) commences a voluntary case under any applicable bankruptcy, insolvency or
other similar law now or hereafter in effect, or consents to the entry of an order for relief in an involuntary case under any such law; (ii) consents to the appointment of or taking possession by a receiver, liquidator, assignee,
síndico, custodian, trustee, sequestrator or similar official for the Company or any of its Significant Subsidiaries or for all or substantially all of the Company’s property and assets of those of any of its Significant
Subsidiaries or (iii) effects any general assignment for the benefit of creditors; and (f) (i) the Concession Title shall cease to grant to the Company the rights provided therein as of the date hereof and such cessation has had a material
adverse effect on the Company and its Subsidiaries taken as a whole, (ii) (x) the Concession Title shall for any reason be terminated and not reinstated within 30 days or (y) rights provided therein which were originally exclusive to
the 

  
 9 

 
Company shall become nonexclusive and the cessation of such exclusivity has had a material adverse effect on the Company and its Subsidiaries taken as a whole, or (iii) the operations of
the Northeast Rail Lines shall be commandeered or repossessed (a requisa) for a period of 90 days or more.  
 If an Event of
Default occurs and is continuing under the Indenture, the Trustee or the Holders of at least 25% in aggregate principal amount of the Notes then outstanding, by written notice to the Company (and to the Trustee if such notice is given by the
Holders), may, and the Trustee at the request of such Holders shall, declare the principal of and interest, Additional Amounts, or premium, if any, on the Notes to be immediately due and payable. 

Holders may not enforce the Indenture or the Notes except as provided in the Indenture. The Trustee may require indemnity satisfactory to it
before it enforces the Indenture or the Notes. Subject to certain limitations, Holders of a majority in principal amount of the Notes then outstanding may direct the Trustee in its exercise of any trust or power. 

 

	18.	Additional Amounts. 

 Any payments by the Company under or with respect to the Notes may
require the payment of Additional Amounts as may become payable under Section 4.08 of the Indenture. 
  

	19.	Trustee Dealings with Company. 

 The Trustee under the Indenture, in its individual or
any other capacity, may make loans to, accept deposits from and perform services for the Company or its Affiliates and may otherwise deal with the Company or its Affiliates as if it were not the Trustee. 

 

	20.	No Personal Liability of Incorporators, Stockholders, Officers, Directors, or Employees. 

No recourse for the payment of the principal of, premium, if any, or interest on any of the Notes issued under the Indenture or for any claim
based on the Indenture or otherwise in respect hereof, and no recourse under or upon any obligation, covenant or agreement of the Company in the Indenture or in any of the Notes or because of the creation of any indebtedness represented thereby,
shall be had against any incorporator, stockholder, officer, director, employee or controlling person of the Company or of any successor Person thereof. Each Holder, by accepting the Notes, waives and releases all such liability. 

 

	21.	Authentication. 

 This Note shall not be valid until the Trustee or authenticating agent
signs the certificate of authentication on the other side of this Note. 
  

	22.	Abbreviations. 

 Customary abbreviations may be used in the name of a Holder or an
assignee, such as: TEN COM (= tenants in common), TEN ENT (= tenants by the entireties), JT TEN (= joint tenants with right of survivorship and not as tenants in common), CUST (= Custodian) and U/G/M/A (= Uniform Gifts to Minors Act).

  
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 The Company will furnish to any Holder upon written request and without charge a copy of the
Indenture. Requests may be made to Kansas City Southern de México, S.A. de C.V., c/o Kansas City Southern, 427 West 12th Street, Kansas City, MO 64105, Attention: Treasurer. 

  
 11 

 OPTION OF HOLDER TO ELECT PURCHASE 

If you wish to have this Note purchased by the Company pursuant to Section 4.04 of the Indenture, check the Box:   ̈ 
 If you wish to have a portion of this Note purchased by the Company pursuant to
Section 4.04 of the Indenture, state the amount: U.S.$         
  

			
	 Date:
  
	 	
	Your Signature:	 	  

		 	(Sign exactly as your name appears on the other side of this Note)

 Signature
Guarantee:                                       
               

  
 12 

 SCHEDULE OF EXCHANGES OF INTERESTS IN THE GLOBAL NOTE 

The initial outstanding principal amount of this Global Note is U.S.$249,030,000. The following exchanges of a part of this Global Note for an
interest in another Global Note or for a Certificated Note, or exchanges of a part of another Global or Certificated Note for an interest in this Global Note, have been made: 
  

									
	 Date of
Exchange
	  	 Amount of
decrease in
Principal
Amount
	  	 Amount of
increase
in
Principal
Amount of this
Global Note
	  	
Principal
Amount of this
Global Note
following such
decrease or
increase
	  	 Signature of
authorized
signatory of
Trustee
or
Custodian

		  		  		  		  	
		  		  		  		  	

  
 13Form of Medium-Term Notes, Series K, Notes Linked to a Domestic ETF Basket

 Exhibit 4.1 

[Face of Note] 

Unless this certificate is presented by an authorized representative of The Depository Trust Company, a New York corporation
(“DTC”), to the Company or its agent for registration of transfer, exchange or payment, and any certificate issued is registered in the name of Cede & Co. or in such other name as requested by an authorized representative
of DTC (and any payment is made to Cede & Co. or such other entity as is requested by an authorized representative of DTC), 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. 
  

			
	 CUSIP NO. 94986RRS2

REGISTERED NO. __
	  	FACE AMOUNT: $___________

 WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Notes Linked to a Domestic ETF Basket 

due May 7, 2020 

WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware (hereinafter
called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay to CEDE & Co., or registered assigns, an amount equal to the
Redemption Amount (as defined below), in such coin or currency of the United States of America as at the time of payment is legal tender for payment of public and private debts, on the Stated Maturity Date. The “Initial Stated Maturity
Date” shall be May 7, 2020. If no Market Disruption Event (as defined below) occurs or is continuing with respect to a Basket Component (as defined below) on the final scheduled Calculation Day (as defined below), the Initial Stated
Maturity Date will be the “Stated Maturity Date.” If a Market Disruption Event occurs or is continuing with respect to a Basket Component on the final scheduled Calculation Day, the “Stated Maturity Date” shall be
the later of (i) three Business Days (as defined below) after the postponed final Calculation Day with respect to such Basket Component (or, if the final Calculation Day is postponed with respect to more than one Basket Component, three
Business Days after the latest postponed Calculation Day) and (ii) the Initial Stated Maturity Date. This Security shall not bear any interest. 

Any payments on this Security at Maturity will be made against presentation of this Security at the office or agency of the
Company maintained for that purpose in the City of Minneapolis, Minnesota and at any other office or agency maintained by the Company for such purpose. 

 “Face Amount” shall mean, when used with respect to this
Security, the amount set forth on the face of this Security as its “Face Amount.” 
 Determination of Redemption Amount 

The “Redemption Amount” of this Security will equal: 

 

	 	•	 	 if the Average Ending Price is greater than the Starting Price: the Face Amount plus: 

 

																							
	 	 	Face Amount	 	  x  	 	 	 	 Average Ending Price – Starting Price
	 	 	 	  x  	 		 	Participation Rate	 	 	 	; or	 	
	 	 	 	 	 	 	Starting Price	 	 	 	 		 	 	 	 	 

  

	 	•	 	 if the Average Ending Price is less than or equal to the Starting Price: the Face Amount. 

“Basket” shall mean a basket comprised of the following Basket Components, with the return of each Basket
Component having the weighting noted parenthetically: SPDR S&P 500 ETF Trust (60%); SPDR S&P MidCap 400 ETF Trust (20%); and iShares Russell 2000 ETF (20%). 

“Basket Component” shall mean each of the SPDR S&P 500 ETF Trust, the SPDR S&P MidCap 400 ETF Trust
and the iShares Russell 2000 ETF. 
 “Underlying Index” shall mean each of the S&P 500 Index, the
S&P MidCap 400 Index and the Russell 2000 Index. 
 The “Pricing Date” shall mean October 31,
2013. 
 The “Starting Price” is 100. 

The “Average Ending Price” will be calculated based on the weighted returns of the Basket Components and will
be equal to the product of (i) 100 and (ii) an amount equal to 1 plus the sum of: (A) 60% of the Average Component Return of the SPDR S&P 500 ETF Trust; (B) 20% of the Average Component Return of the SPDR S&P MidCap 400
ETF Trust; and (C) 20% of the Average Component Return of the iShares Russell 2000 ETF. 
 The “Average
Component Return” of a Basket Component will be equal to: 
 Average Component Price – Initial Component Price 

Initial Component Price 

where, 
  

	 	•	 	 the “Initial Component Price” is the Fund Closing Price of such Basket Component on the Pricing Date; and 

  
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	 	•	 	 the “Average Component Price” will be the arithmetic average of the Fund Closing Prices of such Basket Component on the
Calculation Days. 

 The Initial Component Prices of the Basket Components are as follows: SPDR S&P
500 ETF Trust ($175.73); SPDR S&P MidCap 400 ETF Trust ($234.52); and iShares Russell 2000 ETF ($109.23). 
 The
“Fund Closing Price,” with respect to a Basket Component on any Trading Day, means the product of (i) the Closing Price of one share of such Basket Component (or one unit of any other security for which a Fund Closing Price
must be determined) on such Trading Day and (ii) the Adjustment Factor applicable to such Basket Component on such Trading Day. 

The “Closing Price” with respect to a share of a Basket Component (or one unit of any other security for
which a Closing Price must be determined) on any Trading Day means the price, at the scheduled weekday closing time, without regard to after hours or any other trading outside the regular trading session hours, of the share on the principal United
States securities exchange registered under the Securities Exchange Act of 1934, as amended, on which the share (or any such other security) is listed or admitted to trading. 

The “Adjustment Factor” means, with respect to a share of a Basket Component (or one unit of any other
security for which a Fund Closing Price must be determined), 1.0, subject to adjustment in the event of certain events affecting the shares of such Basket Component. See “Anti-dilution Adjustments Relating To A Basket Component; Alternate
Calculation—Anti-dilution Adjustments” below. 
 The “Participation Rate” is 100%. 

“Business Day” shall mean a day, other than a Saturday or Sunday, that is neither a legal holiday nor a day
on which banking institutions are authorized or required by law or regulation to close in New York, New York. 
 A
“Trading Day” with respect to a Basket Component means a day, as determined by the Calculation Agent, on which the Relevant Exchange (as defined below) and each Related Exchange (as defined below) with respect to a Basket Component,
or any successor thereto, if applicable, are scheduled to be open for trading for their respective regular trading sessions. 

The “Related Exchange” for a Basket Component means each exchange or quotation system where trading has a
material effect (as determined by the Calculation Agent) on the overall market for futures or options contracts relating to such Basket Component. 

The “Relevant Exchange” for a Basket Component means the primary exchange or quotation system on which shares
(or other applicable securities) of such Basket Component are traded, as determined by the Calculation Agent. 
 The
“Calculation Days” shall be quarterly on the last Trading Day of each January, April, July and October, commencing January 2014 and ending April 2020. A Calculation Day is 

  
 3 

 
subject to postponement due to the occurrence of a Market Disruption Event. If a Market Disruption Event occurs or is continuing with respect to a Basket Component on a Calculation Day, such
Calculation Day for such Basket Component will be postponed to the first succeeding Trading Day for such Basket Component on which a Market Disruption Event for such Basket Component has not occurred and is not continuing. If such first succeeding
Trading Day has not occurred as of the eighth Trading Day for such Basket Component after the originally scheduled Calculation Day for such Basket Component, that eighth Trading Day shall be deemed the applicable Calculation Day. If a Calculation
Day has been postponed eight Trading Days for a Basket Component after an originally scheduled Calculation Day for such Basket Component, and a Market Disruption Event occurs or is continuing with respect to such Basket Component on such eighth
Trading Day, the Calculation Agent will determine the Closing Price of such Basket Component on such eighth Trading Day based on its good faith estimate of the value of the shares (or other applicable securities) of such Basket Component as of the
Close of Trading (as defined below) on such eighth Trading Day. Notwithstanding a postponement of a Calculation Day for a particular Basket Component due to a Market Disruption Event with respect to such Basket Component, an originally scheduled
Calculation Day will remain a Calculation Day for any Basket Component not affected by a Market Disruption Event. See “—Market Disruption Events.” 

“Calculation Agent Agreement” shall mean the Calculation Agent Agreement dated as of May 29, 2012
between the Company and the Calculation Agent, as amended from time to time. 
 “Calculation Agent” shall
mean the Person that has entered into the Calculation Agent Agreement with the Company providing for, among other things, the determination of the Average Ending Price and the Redemption Amount, which term shall, unless the context otherwise
requires, include its successors under such Calculation Agent Agreement. The initial Calculation Agent shall be Wells Fargo Securities, LLC. Pursuant to the Calculation Agent Agreement, the Company may appoint a different Calculation Agent from time
to time after the initial issuance of this Security without the consent of the Holder of this Security and without notifying the Holder of this Security. 

Market Disruption Events 

A “Market Disruption Event” means, with respect to a Basket Component, any of the following events as
determined by the Calculation Agent in its sole discretion: 
  

	 	(A)	 The occurrence or existence of a material suspension of or limitation imposed on trading by the Relevant Exchange or otherwise relating to the
shares (or other applicable securities) of such Basket Component or any Successor Fund (as defined below) on the Relevant Exchange at any time during the one-hour period that ends at the Close of Trading on such day, whether by reason of movements
in price exceeding limits permitted by such Relevant Exchange or otherwise. 

  

	 	(B)	 The occurrence or existence of a material suspension of or limitation imposed on trading by any Related Exchange or otherwise in futures or options
contracts relating to the shares (or other applicable securities) of such Basket Component or any Successor Fund on any Related Exchange at any time during the one-hour 

  
 4 

	 	 
period that ends at the Close of Trading on that day, whether by reason of movements in price exceeding limits permitted by the Related Exchange or otherwise. 

 

	 	(C)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the ability of market participants in
general to effect transactions in, or obtain market values for, shares (or other applicable securities) of such Basket Component or any Successor Fund on the Relevant Exchange at any time during the one-hour period that ends at the Close of Trading
on that day. 

  

	 	(D)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the ability of market participants in
general to effect transactions in, or obtain market values for, futures or options contracts relating to shares (or other applicable securities) of such Basket Component or any Successor Fund on any Related Exchange at any time during the one-hour
period that ends at the Close of Trading on that day. 

  

	 	(E)	 The closure of the Relevant Exchange or any Related Exchange with respect to such Basket Component or any Successor Fund prior to its Scheduled
Closing Time unless the earlier closing time is announced by the Relevant Exchange or Related Exchange, as applicable, at least one hour prior to the earlier of (1) the actual closing time for the regular trading session on such Relevant
Exchange or Related Exchange, as applicable, and (2) the submission deadline for orders to be entered into the Relevant Exchange or Related Exchange, as applicable, system for execution at the Close of Trading on that day.

  

	 	(F)	 The Relevant Exchange or any Related Exchange with respect to such Basket Component or any Successor Fund fails to open for trading during its
regular trading session. 

 For purposes of determining whether a Market Disruption Event has occurred:

  

	 	(1)	 “Close of Trading” means the Scheduled Closing Time of the Relevant Exchange with respect to such Basket Component or any
Successor Fund; and 

  

	 	(2)	 the “Scheduled Closing Time” of the Relevant Exchange or any Related Exchange on any Trading Day for such Basket Component or any
Successor Fund means the scheduled weekday closing time of such Relevant Exchange or Related Exchange on such Trading Day, without regard to after hours or any other trading outside the regular trading session hours. 

Anti-dilution Adjustments Relating To A Basket Component; Alternate Calculation 

Anti-dilution Adjustments 

The Calculation Agent will adjust the Adjustment Factor with respect to a Basket Component as specified below if any of the
events specified below occurs with respect to such 

  
 5 

 
Basket Component and the effective date or ex-dividend date, as applicable, for such event is after the Pricing Date and on or prior to a Calculation Day. 

The adjustments specified below do not cover all events that could affect a Basket Component. The Calculation Agent may, in
its sole discretion, make additional adjustments to any terms of this Security upon the occurrence of other events that affect or could potentially affect the market price of, or shareholder rights in, such Basket Component, with a view to
offsetting, to the extent practical, any such change, and preserving the relative investment risks of this Security. In addition, the Calculation Agent may, in its sole discretion, make adjustments or a series of adjustments that differ from those
described herein if the Calculation Agent determines that such adjustments do not properly reflect the economic consequences of the events specified herein or would not preserve the relative investment risks of this Security. All determinations made
by the Calculation Agent in making any adjustments to the terms of this Security, including adjustments that are in addition to, or that differ from, those described herein, will be made in good faith and a commercially reasonable manner, with the
aim of ensuring an equitable result. In determining whether to make any adjustment to the terms of this Security, the Calculation Agent may consider any adjustment made by the Options Clearing Corporation or any other equity derivatives clearing
organization on options contracts on the affected Basket Component. 
 For any event described below, the Calculation Agent
will not be required to adjust the Adjustment Factor unless the adjustment would result in a change to the Adjustment Factor then in effect of at least 0.10%. The Adjustment Factor resulting from any adjustment will be rounded up or down, as
appropriate, to the nearest one-hundred thousandth. 
  

	 	(A)	 Stock Splits and Reverse Stock Splits 

If a stock split or reverse stock split has occurred, then once such split has become effective, the Adjustment Factor will
be adjusted to equal the product of the prior Adjustment Factor and the number of securities which a holder of one share (or other applicable security) of the Basket Component before the effective date of such stock split or reverse stock split
would have owned or been entitled to receive immediately following the applicable effective date. 
  

	 	(B)	 Stock Dividends 

If a dividend or distribution of shares (or other applicable securities) to which this Security is linked has been made by a
Basket Component ratably to all holders of record of such shares (or other applicable security), then the Adjustment Factor will be adjusted on the ex-dividend date to equal the prior Adjustment Factor plus the product of the prior Adjustment Factor
and the number of shares (or other applicable security) of such Basket Component which a holder of one share (or other applicable security) of such Basket Component before the ex-dividend date would have owned or been entitled to receive immediately
following that date; provided, however, that no adjustment will be made for a distribution for which the number of securities of such Basket Component paid or distributed is based on a fixed cash equivalent value. 

  
 6 

	 	(C)	 Extraordinary Dividends 

If an Extraordinary Dividend (as defined below) has occurred, then the Adjustment Factor will be adjusted on the ex-dividend
date to equal the product of the prior Adjustment Factor and a fraction, the numerator of which is the Closing Price per share (or other applicable security) of such Basket Component on the Trading Day preceding the ex-dividend date, and the
denominator of which is the amount by which the Closing Price per share (or other applicable security) of such Basket Component on the Trading Day preceding the ex-dividend date exceeds the Extraordinary Dividend Amount (as defined below). 

For purposes of determining whether an Extraordinary Dividend has occurred: 

 

	 	(1)	 “Extraordinary Dividend” means any cash dividend or distribution (or portion thereof) that the Calculation Agent determines, in
its sole discretion, is extraordinary or special; and 

  

	 	(2)	 “Extraordinary Dividend Amount” with respect to an Extraordinary Dividend for the securities of such Basket Component will equal
the amount per share (or other applicable security) of such Basket Component of the applicable cash dividend or distribution that is attributable to the Extraordinary Dividend, as determined by the Calculation Agent in its sole discretion.

 A distribution on the securities of such Basket Component described below under the section entitled
“—Reorganization Events” below that also constitutes an Extraordinary Dividend will only cause an adjustment pursuant to that “—Reorganization Events” section. 

 

	 	(D)	 Other Distributions 

If a Basket Component declares or makes a distribution to all holders of the shares (or other applicable security) of such
Basket Component of any non-cash assets, excluding dividends or distributions described under the section entitled “—Stock Dividends” above, then the Calculation Agent may, in its sole discretion, make such adjustment (if any) to the
Adjustment Factor as it deems appropriate in the circumstances. If the Calculation Agent determines to make an adjustment pursuant to this paragraph, it will do so with a view to offsetting, to the extent practical, any change in the economic
position of a holder of this Security that results solely from the applicable event. 
  

	 	(E)	 Reorganization Events 

If a Basket Component, or any Successor Fund, is subject to a merger, combination, consolidation or statutory exchange of
securities with another exchange traded fund, and such Basket Component to which this Security is linked is not the surviving entity (a “Reorganization Event”), then, on or after the

  
 7 

 
date of such event, the Calculation Agent shall, in its sole discretion, make an adjustment to the Adjustment Factor or the method of determining the Redemption Amount or any other terms of this
Security as the Calculation Agent determines appropriate to account for the economic effect on this Security of such event, and determine the effective date of that adjustment. If the Calculation Agent determines that no adjustment that it could
make will produce a commercially reasonable result, then the Calculation Agent may deem such event a Liquidation Event (as defined below). 

Liquidation Events 

If a Basket Component is de-listed, liquidated or otherwise terminated (a “Liquidation Event”), and a
successor or substitute exchange traded fund exists that the Calculation Agent determines, in its sole discretion, to be comparable to such Basket Component, then, upon the Calculation Agent’s notification of that determination to the Trustee
and the Company, any subsequent Fund Closing Price for such Basket Component will be determined by reference to the Fund Closing Price of such successor or substitute exchange traded fund (such exchange traded fund being referred to herein as a
“Successor Fund”), with such adjustments as the Calculation Agent determines are appropriate to account for the economic effect of such substitution on the holder of this Security. 

If a Basket Component undergoes a Liquidation Event prior to, and such Liquidation Event is continuing on, the date that any
Fund Closing Price of such Basket Component is to be determined and the Calculation Agent determines that no Successor Fund is available at such time, then the Calculation Agent will, in its discretion, calculate the Fund Closing Price for such
Basket Component on such date by a computation methodology that the Calculation Agent determines will as closely as reasonably possible replicate such Basket Component, provided that if the Calculation Agent determines in its discretion that it is
not practicable to replicate such Basket Component (including but not limited to the instance in which the sponsor of the index underlying such Basket Component discontinues publication of that index), then the Calculation Agent will calculate the
Fund Closing Price for such Basket Component in accordance with the formula last used to calculate such Fund Closing Price before such Liquidation Event, but using only those securities that were held by such Basket Component immediately prior to
such Liquidation Event without any rebalancing or substitution of such securities following such Liquidation Event. 
 If a
Successor Fund is selected or the Calculation Agent calculates the Fund Closing Price as a substitute for such Basket Component, such Successor Fund or Fund Closing Price will be used as a substitute for such Basket Component for all purposes,
including for purposes of determining whether a Market Disruption Event exists. 
 If any event is both a Reorganization
Event and a Liquidation Event, such event will be treated as a Reorganization Event for purposes of this Security unless the Calculation Agent makes the determination referenced in the last sentence of the section entitled “—Anti-dilution
Adjustments—Reorganization Events” above. 

  
 8 

 Alternate Calculation 

If at any time the method of calculating a Basket Component or a Successor Fund, or the related Underlying Index, is changed
in a material respect, or if a Basket Component or a Successor Fund is in any other way modified so that such Basket Component does not, in the opinion of the Calculation Agent, fairly represent the price of the securities of such Basket Component
or such Successor Fund had such changes or modifications not been made, then the Calculation Agent may, at the close of business in New York City on the date that any Fund Closing Price 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 Closing Price of an exchange traded fund comparable to such Basket Component or such Successor Fund, as the case may be, as if such changes or
modifications had not been made, and calculate the Fund Closing Price and the Redemption Amount with reference to such adjusted Closing Price of such Basket Component or such Successor Fund, as applicable. 

Calculation Agent 

The Calculation Agent will determine the Redemption Amount and the Average Ending Price. In addition, the Calculation Agent
will (i) determine if adjustments are required to the Fund Closing Price and/or the Adjustment Factor of a Basket Component under the circumstances described in this Security, (ii) if a Basket Component undergoes a Liquidation Event,
select a Successor Fund or, if no Successor Fund is available, determine the Fund Closing Price of such Basket Component, and (iii) determine whether a Market Disruption Event has occurred. 

The Company covenants that, so long as this Security is Outstanding, there shall at all times be a Calculation Agent (which
shall be a broker-dealer, bank or other financial institution) with respect to this Security. 

All determinations made by the Calculation Agent with respect to this Security will be at the sole discretion of the
Calculation Agent and, in the absence of manifest error, will be conclusive for all purposes and binding on the Company and the Holder of this Security. All percentages and other amounts resulting from any calculation with respect to this Security
will be rounded at the Calculation Agent’s discretion. 
 Redemption and Repayment 

This Security is not subject to redemption at the option of the Company or repayment at the option of the Holder hereof prior
to May 7, 2020. This Security is not entitled to any sinking fund. 
 Acceleration 

If an Event of Default, as defined in the Indenture, with respect to this Security shall occur and be continuing, the
Redemption Amount (calculated as set forth in the next sentence) of this Security 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 Redemption Amount hereof calculated as provided herein; provided, however, that the Redemption Amount will be calculated using (i) the Fund Closing Prices of the Basket Components ascertained on the
Calculation Day(s) that occurred before the 

  
 9 

 
date of acceleration and (ii) the Fund Closing Prices of the Basket Components ascertained on each of the Trading Days leading up to and including the date of acceleration in such number
equal to the number of Calculation Days scheduled to occur on or after the date of acceleration. 
  

 

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. 
 Unless the certificate of authentication
hereon has been executed by the Trustee referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall not be entitled to any benefit
under the Indenture or be valid or obligatory for any purpose. 
 [The remainder of this page has been left intentionally blank] 

  
 10 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly executed
under its corporate seal. 
 DATED: _____________ 
  

					
	WELLS FARGO & COMPANY
		
	By:	 	 
		
		 	 
			
		 	Its:	 	 

 [SEAL] 
  

					
		
	Attest:	 	 
		
		 	 
			
		 	Its:	 	 

 TRUSTEE’S CERTIFICATE OF 

AUTHENTICATION 
 This is one of the Securities of the 

series designated therein described 
 in the within-mentioned Indenture. 
 CITIBANK, N.A., 

    as Trustee 
  

			
		
	By:	 	 
		 	Authorized Signature

 OR 

WELLS FARGO BANK, N.A., 
     as
Authenticating Agent for the Trustee 
  

			
		
	By:	 	 
		 	Authorized Signature

  
 11 

 [Reverse of Note] 

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Notes Linked to a Domestic ETF Basket 

due May 7, 2020 

This Security is one of a duly authorized issue of securities of the Company (herein called the
“Securities”), issued and to be issued in one or more series under an indenture dated as of July 21, 1999, as amended or supplemented from time to time (herein called the “Indenture”), between 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 statement of the
respective rights, limitations of rights, duties and immunities thereunder of the Company, the Trustee and the Holders of the Securities, and of the terms upon which the Securities are, and are to be, authenticated and delivered. This Security is
one of the series of the Securities designated as Medium-Term Notes, Series K, of the Company, which series is limited to an aggregate principal amount or face amount, as applicable, of $25,000,000,000 or the equivalent thereof in one or more
foreign or composite currencies. The amount payable on the Securities of this series may be determined by reference to the performance of one or more equity-, commodity- or currency-based indices, exchange traded funds, securities, commodities,
currencies, statistical measures of economic or financial performance, or a basket comprised of two or more of the foregoing, or any other market measure or may bear interest at a fixed rate or a floating rate. The Securities of this series may
mature at different times, be redeemable at different times or not at all, be repayable at the option of the Holder at different times or not at all and be denominated in different currencies. 

Article Sixteen of the Indenture shall not apply to this Security. 

The Securities are issuable only in registered form without coupons and will be either
(a) book-entry securities represented by one or more Global Securities recorded in the book-entry system maintained by the Depositary or (b) certificated
securities issued to and registered in the names of, the beneficial owners or their nominees. 
 The Company agrees, to the
extent permitted by law, not to voluntarily claim the benefits of any laws concerning usurious rates of interest against a Holder of this Security. 

Modification and Waivers 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights
and obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the 

  
 12 

 
time Outstanding of all series to be affected, acting together as a class. The Indenture also contains provisions permitting the Holders of a majority in principal amount of the Securities of all
series at the time Outstanding affected by certain provisions of the Indenture, acting together as a class, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain
past defaults under the Indenture and their consequences may be waived under the Indenture by the Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such
series. Solely for the purpose of determining whether any consent, waiver, notice or other action or Act to be taken or given by the Holders of Securities pursuant to the Indenture has been given or taken by the Holders of Outstanding Securities in
the requisite aggregate principal amount, the principal amount of this Security will be deemed to be equal to the amount set forth on the face hereof as the “Face Amount” hereof. Any such consent or waiver by the Holder of this Security
shall be conclusive and binding upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not notation of such consent or
waiver is made upon this Security. 
 Defeasance 

Section 403 and Article Fifteen of the Indenture and the provisions of clause (ii) of Section 401(1)(B) of the
Indenture, relating to defeasance at any time of (a) the entire indebtedness on this Security and (b) certain restrictive covenants and certain Events of Default, upon compliance by the Company with certain conditions set forth therein,
shall not apply to this Security. The remaining provisions of Section 401 of the Indenture shall apply to this Security. 
 Authorized
Denominations 
 This Security is issuable only in registered form without coupons in denominations of $1,000 or any
amount in excess thereof which is an integral multiple of $1,000. 
 Registration of Transfer 

Upon due presentment for registration of transfer of this Security at the office or agency of the Company in the City of
Minneapolis, Minnesota, a new Security or Securities of this series, with the same terms as this Security, in authorized denominations for an equal aggregate Face Amount will be issued to the transferee in exchange herefor, as provided in the
Indenture and subject to the limitations provided therein and to the limitations described below, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is exchangeable for definitive Securities in registered form only if (x) the Depositary notifies the
Company that it is unwilling or unable to continue as Depositary for this Security or if at any time the Depositary ceases to be a clearing agency registered under the Securities Exchange Act of 1934, as amended, and a successor depositary is not
appointed within 90 days after the Company receives such notice or becomes aware of such ineligibility, (y) the Company in its sole discretion determines that this Security shall be exchangeable for definitive Securities in registered form
and notifies the Trustee thereof or (z) an Event of Default with respect to the Securities represented hereby has occurred and is continuing. If this Security is exchangeable pursuant to the preceding sentence, it shall be exchangeable for
definitive Securities in registered 

  
 13 

 
form, having the same date of issuance, Stated Maturity Date and other terms and of authorized denominations aggregating a like amount. 

This Security may not be transferred except as a whole by the Depositary to a nominee of the Depositary or by a nominee of the
Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor. Except as provided above, owners of beneficial interests in this Global
Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture. 

Prior to due presentment of this Security for registration of transfer, the Company, the Trustee and any agent of the Company
or the Trustee may treat the Person in whose name this Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 Obligation of the Company Absolute 

No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation
of the Company, which is absolute and unconditional, to pay the Redemption Amount at the times, place and rate, and in the coin or currency, herein prescribed, except as otherwise provided in this Security. 

No Personal Recourse 

No recourse shall be had for the payment of the Redemption Amount, or for any claim based hereon, or otherwise in respect
hereof, or based on or in respect of the Indenture or any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or any successor corporation, whether by virtue of
any constitution, statute 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 issuance hereof, expressly waived and released.

 Defined Terms 

All terms used in this Security which are defined in the Indenture shall have the meanings assigned to them in the Indenture
unless otherwise defined in this Security. 
 Governing Law 

This Security shall be governed by and construed in accordance with the law of the State of New York, without regard to
principles of conflicts of laws. 

  
 14 

 ABBREVIATIONS 

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

							
	 TEN COM
	 	 —
	  	as tenants in common	  	
				
	 TEN ENT
	 	 —
	  	as tenants by the entireties	  	
				
	 JT TEN
	 	 —
	  	 as joint tenants with right
 of survivorship and
not
 as tenants in common
	  	

  

							
	 UNIF GIFT MIN ACT —  
	 	 	  	Custodian	  	 
		 	(Cust)	  		  	(Minor)

  

	
	Under Uniform Gifts to Minors Act
	   

	(State)

 Additional abbreviations may also be used though not in the above list. 

FOR VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 

 

	
	 Please Insert Social Security or

Other Identifying Number of Assignee

	   

  
       

 

      

 

      

 
 (PLEASE
PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL ZIP CODE OF ASSIGNEE)

  
 15 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute and
appoint __________________ attorney 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 written upon the face of the
within instrument in every particular, without alteration or enlargement or any change whatever. 

  
 16

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