I, [TRANSFEROR'S NAME], hereby transfer to [CUSTODIAN'S NAME], as custodian for [MINOR'S NAME] under the Uniform Transfers to Minors Act, Certificate No. [NUMBER], representing [NUMBER] shares of common stock in [CORPORATION'S NAME], a [STATE] corporation.

Date:

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TRANSFEROR'S SIGNATURE

As custodian for [MINOR'S NAME], [CUSTODIAN'S NAME] hereby acknowledges receipt of the shares of common stock described above under the Uniform Transfers to Minors Act.

Date:

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CUSTODIAN'S SIGNATURE