Common use of USE ONLY Clause in Contracts

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE FILED ON ANY PORTION OF YOUR LIABILITY WHICH REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 1-2015)

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE Originator’s ID number Originator Code FILED ON ANY PORTION OF YOUR LIABILITY WHICH Name Title REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 17-2015)2020) Part 2 — Taxpayer’s Copy

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE FILED ON ANY PORTION OF YOUR LIABILITY WHICH REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 1-2015)Date

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE FILED ON ANY PORTION OF YOUR LIABILITY WHICH REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 1-2015)2017) Part 2 — Taxpayer’s Copy

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE Originator’s ID number Originator Code FILED ON ANY PORTION OF YOUR LIABILITY WHICH Name Title REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 18-2015)2022) Part 2 — Taxpayer’s Copy

USE ONLY. AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs Agreement Review Cycle Earliest CSED Check box if pre-assessed modules included Originator’s ID number Originator Code A NOTICE OF FEDERAL TAX LIEN (Check one box below) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE FILED ON ANY PORTION OF YOUR LIABILITY WHICH REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY Name Title PAYMENT UNDER THE AFFORDABLE CARE ACT. Agreement examined or approved by (Signature, title, function) Date Catalog Number 16644M xxx.xxx.xxx Form 433-D (Rev. 1-20152017)