Exhibit 10.1
| UBS Bank USA | |||
Variable Credit Line Account Number: (if applicable) | ||||
5V |
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| Fixed Credit Line Account Number: (if aaplicable) | |||
Credit Line Account Application and | 5F |
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Agreement for Individuals | SS# / TIN |
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| Internal Use Only | |
For Internal Use Only |
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Variable Credit Line Account at UBS Bank USA |
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| 5V |
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Fixed Credit Line Account at UBS Bank USA |
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| 5F |
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Collateral Account(s) at UBS Financial Services Inc. |
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Insert the information below for each UBS Financial Services Inc. account to be pledged to secure the Borrower’s credit line. | |||||
Full Collateral (Securities) Account Title | Branch | Account Number | FA# | ||
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6) | |||||
Credit Line Account | ||
Select the type of credit line account: |
| Select the type of Credit Line Account:* |
o Variable Credit Line Account |
| o Sole Borrower |
o Fixed Credit Line Account |
| o Joint Borrowers |
o Both |
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If you do not indicate your preference you will be deemed to | Please read carefully the Joint Credit Line Account Agreement | |
have selected the “Both” option. |
| section of the attached Credit Line Agreement. |
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* Any person, whether married, unmarried or separated, may apply for separate credit. |
Borrower Information | |||||||||||||||||||||||
Complete this section for: a Sole Borrower Account or the Primary Borrower for Joint Borrowers. | |||||||||||||||||||||||
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Basic Information |
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First Name: |
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| Location of Address: | o Home-Legal Residence | o Business- | ||||||||||||||||
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| Primary | |||||||||||||||||
Last Name: |
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Country of Citizenship: |
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| Street Address: (If a P.O. Box, complete the Additional Address | |||||||||||||||||
o USA o Other (specify) |
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| Information on page 4.) | |||||||||||||||||
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Passport/CEDULA and Green Card#: (If non-U.S. and no SS# |
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specified) |
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Passport/CEDULA Country of Issuance: |
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Borrower Financial Information. If you share assets with another person, please provide financial information (e.g. annual income, liquid assets, net worth) per individual. | |||||||||||||||||||||||
Annual Income: | Liquid Assets: |
| Is the Borrower a control person of UBS AG or its subsidiaries or | ||||||||||||||||||||
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| affiliates?:* | |||||||||||||||||||
Net Worth (exclusive of residence): |
| o Yes o No If yes, please specify company and %: | |||||||||||||||||||||
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Do you derive a substantial amount of your income/wealth |
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(over 50%) from a country outside of the United States? |
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o No o Yes If yes, specify: |
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Country(ies) |
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HA Rev 07/08 HA LOAD SPEDOC UX EHA V101 |
| Ó 2008 UBS Bank USA. All rights reserved. |
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| Sign and date the application on page 6 |
UBS Bank USA | ||||
Variable Credit Line Account Number: (if applicable) | ||||
5V |
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| Fixed Credit Line Account Number: (if aaplicable) | |||
| 5F |
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| SS# / TIN |
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| Internal Use Only | |
Borrower Personal Information |
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Date of Birth: |
| Is the Borrower an immediate family member of an executive officer or | ||||||||||||||||||||||||||||||||
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| member of the board of directors of UBS AG? Immediate family member | |||||||||||||||||||||||||||||||
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| means a spouse or any other relative residing in the Borrower’s | ||||||||||||||||||||||||||||||||
Does the Borrower own 10% or more of the shares of any publicly traded company? |
| household to whom the Borrower lends financial support. | ||||||||||||||||||||||||||||||||
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o Yes o No If yes, please specify company: |
| Subsidiary or Affiliate | Employee Name and SS# | |||||||||||||||||||||||||||||||
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Is the Borrower an officer or member of the board of directors of |
| Will any of the loan proceeds be used to repay any debt or obligation owed | ||||||||||||||||||||||||||||||||
UBS AG, its subsidiaries or affiliates? |
| to, or purchase an asset from, UBS AG or its subsidiaries or affiliates? | ||||||||||||||||||||||||||||||||
o Yes o No If yes, please specify: |
| o Yes o No If yes, please specify: | ||||||||||||||||||||||||||||||||
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Subsidiary or Affiliate |
| Employee Name and SS# |
| Subsidiary or Affiliate | ||||||||||||||||||||||||||||||
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* For purposes of these questions, “control” means a person or entity that either (a) owns, controls or has the power to vote 25% or more of any class of voting securities, (b) has the ability to control the election of the majority of the directors of a company, or (c) has the power to exercise a controlling influence over management policies. A person or entity is presumed to have control of a company if the person or entity owns, controls or has the power to vote 10% or more of any class of voting securities of the company and (i) the person is an executive officer or director of the company or (ii) no other person has a greater percentage of that class of voting securities. | ||||||||||||||||||||||||||||||||||
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Joint Borrowers |
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Complete this section for the Additional Borrower in the case where there are Joint Borrowers. | ||||||||||||||||||||||||||||||||||
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Basic Joint Borrower Information |
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Joint Borrower First Name: | Middle Name: |
| Location of Address o Home-Legal Residence o Business | |||||||||||||||||||||||||||||||
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| Primary | |||||||||||||||||||||||||||||
Last Name: |
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| Street Address (If a P.O. Box, complete the Additional Address Information | ||||||||||||||||||||||||||||||||
Country of Citizenship: | SS#: |
| on page 4.): | |||||||||||||||||||||||||||||||
o USA o Other (specify) |
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| City: | State: | Zip: | ||||||||||||||||||||||||||||||
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Passport/CEDULA and Green Card#: (If non-U.S. and no SS# specified) |
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| Residence Telephone Number: | ||||||||||||||||||||||||||||||
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Passport/CEDULA Country of Issuance: |
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Joint Borrower Financial Information. If you share assets with another person, please provide financial information (e.g. annual income, liquid assets, net worth) per individual. | ||||||||||||||||||||||||||||||||||
Annual Income: |
| Liquid Assets: |
| Is the Borrower a control person of UBS AG or its subsidiaries or affiliates?:* | ||||||||||||||||||||||||||||||
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| o Yes o No If yes, please specify company and %: | ||||||||||||||||||||||||||||||
Net Worth (exclusive of residence): |
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Do you derive a substantial amount of your income/wealth (over 50%) from a country outside of the United States? |
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o No o Yes If yes, specify: |
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Country(ies) |
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Joint Borrower Personal Information |
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Date of Birth: |
| Is the Borrower an immediate family member of an executive officer or | ||||||||||||||||||||||||||||||||
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| member of the board of directors of UBS AG? Immediate family | |||||||||||||||||||||||||||||||
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| member means a spouse or any other relative residing in the Borrower’s | ||||||||||||||||||||||||||||||||
Does the Borrower own 10% or more of the shares of any publicly |
| household to whom the Borrower lends financial support. | ||||||||||||||||||||||||||||||||
traded company?: |
| o Yes o No If yes, please specify: | ||||||||||||||||||||||||||||||||
o Yes o No If yes, please specify company: |
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| Subsidiary or Affiliate |
| Employee Name and SS# | ||||||||||||||||||||||||||||||
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Is the Borrower an officer or member of the board of directors of UBS AG, it’s subsidiaries or affiliates? |
| Will any of the loan proceeds be used to repay any debt or obligation owed to, or purchase an asset from, UBS AG or its subsidiaries or affiliates? | ||||||||||||||||||||||||||||||||
o Yes o No If yes, please specify: |
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Subsidiary or Affiliate |
| Employee Name and SS# |
| Subsidiary or Affiliate | ||||||||||||||||||||||||||||||
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* For purposes of these questions, “control” means a person or entity that either (a) owns, controls or has the power to vote 25% or more of any class of voting securities, (b) has the ability to control the election of the majority of the directors of a company, or (c) has the power to exercise a controlling influence over management policies. A person or entity is presumed to have control of a company if the person or entity owns, controls or has the power to vote 10% or more of any class of voting securities of the company and (i) the person is an executive officer or director of the company or (ii) no other person has a greater percentage of that class of voting securities. | ||||||||||||||||||||||||||||||||||
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HA Rev 07/08 HA LOAD SPEDOC UX E HA V101 |
| ©2008 UBS Bank USA. All rights reserved. | ||||||||||||||||||||||||||||||||
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| Sign and date the application on page 6 | ||||||||||||||||||||||||||||||||
2
| UBS Bank USA | |||
Variable Credit Line Account Number: (if applicable) | ||||
5V |
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| Fixed Credit Line Account Number: (if aaplicable) | |||
| 5F |
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| SS# / TIN |
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| Internal Use Only | |
Joint Borrowers
Complete this section for the Additional Borrower in the case where there are Joint Borrowers.
Basic Joint Borrower Information
Joint Borrower First Name: | Middle Name: | Location of Address | o Home-Legal Residence | o Business-Primary | ||||||||||||
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Last Name: |
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| Street Address (If a P.O. Box, complete the Additional Address Information on page 4.): | |||||||||||||
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Country of Citizenship: |
| SS#: |
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o USA o Other (specify) |
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| City: | State: | Zip: | |||||||||
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Passport/CEDULA and Green Card#: (If non-U.S. and no SS# specified) |
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| Residence Telephone Number: |
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Passport/CEDULA Country of Issuance: |
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Joint Borrower Financial Information. If you share assets with another person, please provide financial information (e.g. annual income, liquid assets, net worth) per individual.
Annual Income: | Liquid Assets: | Is the Borrower a control person of UBS AG or its subsidiaries or affiliates?:* | |||||||
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| o Yes o No If yes, please specify company and %: | |||||
Net Worth (exclusive of residence): |
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Do you derive a substantial amount of your income/wealth (over 50%) from |
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o No o Yes If yes, specify: |
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Country(ies) |
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Joint Borrower Personal Information |
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Date of Birth: |
| Is the Borrower an immediate family member of an executive officer or member of the board of directors of UBS AG? Immediate family member means a spouse or any other relative residing in the Borrower's household to whom the Borrower lends financial support. | |||||||
Does the Borrower own 10% or more of the shares of any publicly traded company?: | |||||||||
o Yes o No If yes, please specify company: | o Yes o No If yes, please specify: | ||||||||
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| Subsidiary or Affiliate | Employee Name and SS# | ||||||
Is the Borrower an officer or member of the board of directors of UBS AG, | Will any of the loan proceeds be used to repay any debt or obligation owed to, or purchase an asset from, UBS AG or its subsidiaries or affiliates? | ||||||||
o Yes o No If yes, please specify: | o Yes o No If yes, please specify: | ||||||||
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Subsidiary or Affiliate | Employee Name and SS# | Subsidiary or Affiliate | |||||||
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*For purposes of these questions, “control” means a person or entity that either (a) owns, controls or has the power to vote 25% or more of any class of voting securities, (b) has the ability to control the election of the majority of the directors of a company, or (c) has the power to exercise a controlling influence over management policies. A person or entity is presumed to have control of a company if the person or entity owns, controls or has the power to vote 10% or more of any class of voting securities of the company and (i) the person is an executive officer or director of the company or (ii) no other person has a greater percentage of that class of voting securities. | |||||||||
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Credit Line Account Features |
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Check Writing |
| Alternate Mailing Address for Checks | |||||||
If you would like to receive Credit Line checks for your credit line account, please enroll below: | Print the mailing address for the delivery of checks if different from the address on the checks: | ||||||||
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o Check here if you would like Credit Line checks. |
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Checks will be in the name of the borrower and joint borrower (if any). |
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Please print the address that you would like to appear on your checks. |
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| Wire Instructions for Loan Payment: (In US Dollars) | |||||||
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| Bank Name: UBS AG | |||||||
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| Wire System Address: ABA 026007993 | |||||||
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| For Further Credit to the Account of: UBS Bank USA | ||||||||
| Account Number: 101-WA-792479-000 | ||||||||
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| For the Benefit of: Full Name | ||||||||
| Account Number: 5[F or V] 00000 | ||||||||
HA Rev 07/08 HA LOAD SPEDOC UX E HA V101 | ©2008 UBS Bank USA. All rights reserved. |
| Sign and date the application on page 6 |
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| UBS Bank USA | |||
Variable Credit Line Account Number: (if applicable) | ||||
5V |
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| Fixed Credit Line Account Number: (if aaplicable) | |||
| 5F |
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| SS# / TIN |
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| Internal Use Only | |
Senior Political Affiliation
Are you, any authorized signatories, beneficial owners, trustees, powers of attorney or other individuals with authority to effect transactions, or any of their immediate family members or close associates a:
I) |
| Current U.S. political official (as defined in section B below)? o No o Yes; complete: |
| A) Political Official’s Name: |
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| B) Current Position: | o President | o Vice President | o US Cabinet Member | |||||
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| o Speaker of the House of Representatives | o Supreme Court Justice | ||||||
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| o Chairman of the Joint Chiefs of Staff | o Ambassador | ||||||
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| C) Relationship to Client(s): | o Self | o Immediate family member | o Close associate | |||||
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| o Associates with business or trust |
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II) Current or former Senior non-U.S. political official, non-U.S. Religious Group/Organization, or Senior/Influential o No o Yes; complete: representative of a non-U.S. Religious Group/Organization? | |||||||||
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| Political Official’s Name: |
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| Current or Former Position: |
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| Relationship to Client(s): | o Self | o Immediate family member | o Close associate | |||||
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| o Associates with business or trust |
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Duplicate Party Addendum
Complete this section for each Duplicate Party to receive a duplicate credit line account statement.
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| Internal Location Code (UBS Financial Services Inc. Use Only) | ||||||||||
Name: |
| Country of Citizenship: | ||||||||||
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| o | USA | o | Other (specify): |
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Street Address: |
| City: | State: |
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| Internal Location Code (UBS Financial Services Inc. Use Only) | ||||||||||
Name: |
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| o | USA | o | Other (specify): |
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Street Address: |
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Additional Address Information If your mailing address is a P.O. Box please provide a residential street address below: | ||||||||||||
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First Name: |
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Location of Address: |
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o Home - Legal Residence |
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o Home - Secondary |
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| City: | State: |
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o Other (specify) |
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HA Rev 07/08 HA LOAD SPEDOC UX E HA V101 | ©2008 UBS Bank USA. All rights reserved. |
| Sign and date the application on page 6 |
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| UBS Bank USA | |||
Variable Credit Line Account Number: (if applicable) | ||||
5V |
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| Fixed Credit Line Account Number: (if aaplicable) | |||
| 5F |
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| SS# / TIN |
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| Internal Use Only | |
First Name: |
| Last Name: |
| Street Address: | ||||
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Location of Address: |
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o Home - Legal Residence |
| o Business - Primary |
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o Home - Secondary |
| o Business - Secondary |
| City: | State: |
| ZIP: | |
o Other (specify): |
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HA Rev 07/08 HA LOAD SPEDOC UX E HA V101 | ©2008 UBS Bank USA. All rights reserved. |
| Sign and date the application on page 6 |
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