Silver Fix Settlement

PART I: CLAIMANT IDENTIFICATION

Claimant's Name (First, Middle, Last): *

Co-Claimant's Name (First, Middle, Last):

Entity Name (if claimant is not an individual):

Representative or Custodian Name (if different from Claimant(s) listed above):

Address 1 (street name and number): *

Address 2 (apartment, unit, or box number):

Country: *

City: *

State: *

Zip Code: *

Telephone Number (Home): *

Telephone Number (Work):

Email Address: (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim)

Location(s) from which Claimant entered into Silver Instrument Transactions: *

ITEM 2 - LIST OF BROKERS OR FUTURES COMMISSION MERCHANTS, ACCOUNT NAMES AND ACCOUNT NUMBERS

Please list all brokers or futures commission merchants (“FCMs”) at which you maintained accounts in which you traded or held Physical Silver or Silver Derivatives between January 1, 1999 through and September 6, 2016, inclusive, and the account names and account numbers that were maintained at each broker or FCM.

Broker or FCM

Address:

Telephone Number:

Contact (if any):

Account Name:

Account Number:

Must click Add Info to submit your transactions.

Broker or FCM

Address

Telephone

Contact

Account Name

Account Number

Action

Item 3 - Proof of Qualifying Transactions

Please describe below all of your transactions in Physical Silver or Silver Derivatives between January 1, 1999 and September 6, 2016, inclusive. Please also submit the supporting documentation for your transactions in Physical Silver or Silver Derivatives. The supporting document should also allow the Settlement Administrator to determine whether a transaction in Physical Silver or Silver Derivatives was a U.S.-Related Transactions.

You must provide proof for each and every transaction in Physical Silver or Silver Derivatives, between January 1, 1999 and September 6, 2016, regardless of whether your transaction resulted in a gain or a loss.

If necessary documents are not in your possession, please obtain them or their equivalent from your broker or tax advisor or other sources if it is possible for you to do so.

The Settlement Administrator will determine your Settlement Transaction Volume (as set forth in the Distribution Plan) by analyzing your transactions in Physical Silver or Silver Derivatives.

Your Physical Silver or Silver Derivatives transaction data should always include trade dates. Do not offset opening and closing transactions or provide net position or trading information. It is important that you supply the information requested to the fullest extent possible.

For all Physical Silver or Silver Derivatives, including those traded on a futures exchange (Chicago Board of Trade, Commodity Exchange, Inc., NYSE LIFFE, CME, COMEX), please provide documents reflecting such transactions including daily and monthly brokerage statements or trade confirmations. For all transactions, you must also provide proof you entered into the transaction while you were domiciled in the United States or its territories, or, if domiciled outside the United States or its territories, the trade was transacted by a Person from a location within the United States or its territories.

If you have any of the below transaction information in an electronic form, you are strongly encouraged to submit the information electronically. The following formats are acceptable: ASCII, MS Excel, MS Access, dBase, and electronic filing templates can be found at the Settlement Website, www.SilverFixSettlement.com.

PHYSICAL SILVER

During the Settlement Class Period, for a long or short position, please list each U.S.-Related Transaction in Physical Silver:

Transaction Date:

Long or Short Position in Silver?:

Total Transaction Amount:

Currency of Transaction:

Ounces of Silver Transacted:

Location of Transaction:

Name of Counterparty:

Name of Broker (if applicable):

Must click Add Physical Silver to submit your transactions.

Transaction Date

Long or Short Position in Silver

Total Transaction Amount

Currency of Transaction

Ounces of Silver Transacted

Location of Transaction

Name of Counterparty

Name of Broker

Action

SILVER DERIVATIVES

Silver Forward Contracts
During the Settlement Class Period, provide the following information for each U.S.-Related Transaction in a Silver forward contract:

Transaction Date:

Long or Short Position in Silver:

Total Transaction Amount:

Currency of Transaction:

Ounces of Silver Transacted:

Location of Transaction:

Name of Counterparty:

Name of Broker (if applicable):

Settlement Date / Delivery Date:

Must click Add Silver Forward Contract to submit your transactions.

Transaction Date

Long or Short Position in Silver

Total Transaction Amount

Currency of Transaction

Ounces of Silver Transacted

Location of Transaction

Name of Counterparty

Name of Broker

Settlement / Delivery Date

Action

Silver Futures Contracts
During the Settlement Class Period, provide the following information for each U.S.-Related Transaction in a Silver Derivative futures contract:

Transaction Date:

Long or Short Position in Silver:

Total Transaction Amount:

Currency of Transaction:

Ounces of Silver Transacted:

Location of Transaction:

Exchange:

Name of Broker (if applicable):

Settlement Date / Delivery Date:

Must click Add Silver Future Contract to submit your transactions.

Transaction Date

Long or Short Position in Silver

Total Transaction Amount

Currency of Transaction

Ounces of Silver Transacted

Location of Transaction

Exchange

Name of Broker

Settlement / Delivery Date

Action

Silver Options Contracts
During the Settlement Class Period, please provide the following information for each U.S.-Related Transaction of an option on a Silver Instrument:

Transaction Date:

Long or Short Position in Silver:

Total Transaction Amount:

Currency of Transaction:

Ounces of Silver Transacted:

Location of Transaction:

Name of Counterparty:

Name of Broker (if applicable):

Must click Add Silver Option Contract to submit your transactions.

Transaction Date

Long or Short Position in Silver

Total Transaction Amount

Currency of Transaction

Ounces of Silver Transacted

Location of Transaction

Name of Counterparty

Name of Broker

Action

Silver Swaps
During the Settlement Class Period, provide the following information for each U.S.-Related Transaction in Silver-based swaps. Please only enter legs of the transaction based on Silver:

Transaction Date:

Long or Short Position in Silver:

Total Transaction Amount:

Currency of Transaction:

Ounces of Silver Transacted:

Supplier or Receiver of Silver:

Payer or Receiver of fixed rate:

Location of Transaction:

Name of Counterparty:

Name of Broker (if applicable):

Must click Add Silver Swap to submit your transactions.

Transaction Date

Long or Short Position in Silver

Total Transaction Amount

Currency of Transaction

Supplier or Receiver of Silver

Payer or Receiver of fixed rate

Ounces of Silver Transacted

Location of Transaction

Name of Counterparty

Name of Broker

Action

UPLOAD SUPPORTING DOCUMENTS

All supporting documentation for your positions and transactions should be uploaded to this page prior to moving on to the next step in your online claim submission.

Please use the browse option, by clicking on “Select Files” in the box below, to upload your supporting documentation being submitted to verify all of your positions and transactions.

Select files

Files To Be Uploaded	Size	Action

Item 4 – Consent, Certification and Signature

BY SIGNING AND SUBMITTING THIS PROOF OF CLAIM AND RELEASE, CLAIMANT OR CLAIMANT’S AUTHORIZED REPRESENTATIVE CERTIFIES ON CLAIMANT’S BEHALF AS FOLLOWS

I (we) expressly consent to the release to the Settlement Administrator of any and all documents reflecting my (our) transactions in Physical Silver or Silver Derivatives that may be obtained from third parties, including, but not limited to, my (our) brokerage firm(s), my (our) FCMs, the CME, NYSE LIFFE, CBOT, COMEX, or any other source with this transaction information.

By executing this Proof of Claim and Release, I (we) hereby permit the Settlement Administrator to request from my (our) brokerage firm(s), my (our) FCMs, the CME, NYSE LIFFE, CBOT, COMEX, or any other source with this transaction information relevant information about my (our) transactions in Physical Silver or Silver Derivatives in order to compute any payment that may be due to me (us) from the Net Settlement Fund. I (we) consent to the disclosure of information relating my (our) transactions in Physical Silver or Silver Derivatives and waive any protections provided by any applicable bank secrecy or data privacy laws (whether foreign or domestic), or any similar confidentiality protections with respect to information and transaction data relating to my (our) trades for use in the claims administration process.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) certify that reasonable efforts have been made to locate all information requested in this Proof of Claim and Release above and that all information supplied in connection with this Proof of Claim and Release is true, correct, and complete.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) certify that I (we) have not submitted any other claim covering the same transactions of Physical Silver or Silver Derivatives during the Settlement Class Period and know of no other person having done so on my (our) behalf.

I (we) hereby warrant and represent that I (we) have not assigned or transferred or purported to assign or transfer, voluntarily or involuntarily, any matter released pursuant to the release or any other part or portion thereof.

I (we) understand that the information provided herein is subject to verification, and I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) agree to cooperate in any such verification, including by furnishing additional information to support this claim and by assisting the Settlement Administrator if requested to do so.

I (we) understand that the Settlement Administrator will determine the adequacy of the Claimant’s Proof of Claim and Release and supporting documentation.

I (we) have read the Notice and Proof of Claim and Release, including the descriptions of the Release and Covenant Not to Sue provided for in the Settlement Agreement.

I (we) am (are) a Settlement Class Member and am (are) not one of the individuals or entities excluded from the Settlement Class.

I (we) have not submitted a Request for Exclusion

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) consent to the jurisdiction of the United States District Court for the Southern District of New York (the “Court”) with respect to all matters concerning this Proof of Claim and Release including, without limitation, any efforts to enforce the terms of the Settlement Agreement or any order or judgment of the Court.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) agree to the terms of the Settlement as set forth in the Settlement Agreement and acknowledge being bound by and subject to the terms of any order or judgment that may be entered in the Action, including the Final Approval Order and Judgment. I (we) may obtain a copy of the Settlement Agreement at www.SilverFixSettlement.com.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) acknowledge that this Proof of Claim and Release constitutes a release and covenant not to sue in conformity with Section 12 of the Settlement Agreement in order to receive the appropriate share, if any, of the Settlement Fund. I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) agree that the submission of this Proof of Claim and Release constitutes a full release of and covenant not to sue on the Released Claims against the DB Released Parties as set forth in the Settlement Agreement and at the end of this Proof of Claim and Release.

I (we) acknowledge that, as of the Effective Date of the Settlement, pursuant to the terms set forth in the Settlement Agreement, and by operation of law and the Judgment, I (we) shall be deemed to release and forever discharge and shall be forever enjoined from prosecuting the Released Claims against the DB Released Parties.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) certify that I (we) am (are) not subject to backup withholding under the provisions of Section 3406(a)(1)(C) of the Internal Revenue Code of 1986, as amended, because: (a) the Claimant(s) is (are) exempt from backup withholding; or (b) the Claimant(s) has (have) not been notified by the Internal Revenue Service (the “I.R.S.”) that the Claimant(s) is (are) subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the I.R.S. has notified the Claimant(s) that the Claimant(s) is (are) no longer subject to backup withholding.

I (we) (for myself (ourselves) in the event of an individual claim, and for the Claimant in the event of any other claim) certify that I (we) am (are) not subject to backup withholding under the provisions of Section 3406(a)(1)(C) of the Internal Revenue Code of 1986, as amended, because: (a) the Claimant(s) is (are) exempt from backup withholding; or (b) the Claimant(s) has (have) not been notified by the Internal Revenue Service (the “I.R.S.”) that the Claimant(s) is (are) subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the I.R.S. has notified the Claimant(s) that the Claimant(s) is (are) no longer subject to backup withholding.

I (we) declare or affirm under penalty of perjury that the foregoing statements and the documents and information attached hereto, including the Social Security or Employer Identification Number shown on this Proof of Claim and Release, are true, correct and complete, and that I (we) agree to the above releases and covenants not to sue. I understand that the withholding or misrepresentation of any information described herein may constitute a criminal offense subject to penalties under the law.

Claimant Signature: *

Signature of Authorized Representative (if any):

Capacity of Authorized Representative (e.g., President, Trustee, Custodian, etc.):

REMINDER: YOUR CLAIM FORM AND REQUIRED DATA MUST BE SUBMITTED ONLINE BY 11:59 P.M. EASTERN TIME ON MARCH 1, 2021 OR MAILED AND RECEIVED BY THE SETTLEMENT ADMINISTRATOR NO LATER THAN MARCH 1, 2021.