Exhibit

Hines Securities, Inc. (the “Dealer Manager”) entered into an exclusive dealer manager agreement, dated as of [ ] , 2015 (the “Dealer Manager Agreement”), with HMS Income Fund, Inc., a Maryland corporation (the “ Company ”), that has elected to be treated as a business development company under the Investment Company Act of 1940, as amended, (“ 1940 Act ”) , pursuant to which the Dealer Manager agreed to use its best efforts to solicit subscriptions in connection with the public offering (the “ Offering ”) of up to $1,500,000,000 in shares, of the Company’s common stock, par value $0.001 per share (the “ Shares ”), on a continuous basis, for the purchase price set forth in the Prospectus (as defined below), with a minimum initial investment of $2,500 in the Shares, commencing on the Effective Date (as defined below).

There is no minimum number of Shares required to be sold in the Offering. Therefore, the Company intends to conduct its initial closing (the “Initial Closing”) as soon as practicable after the Effective Date of the Registration Statement (as defined below). After the Initial Closing, the Company intends to conduct closings on a weekly or other periodic basis (each, a “Periodic Closing”) until conclusion of the Offering. All subscription payments will be placed in a segregated account and held in trust for the subscribers’ benefit, pending release to the Company at the next scheduled Periodic Closing or achievement of the relevant Minimum Offering (as defined below), as applicable. While the Company has no minimum offering amount and may execute the sale of Shares immediately following effectiveness of the Registration Statement, certain states may require the Company to sell a minimum number or dollar amount of Shares prior to selling Shares to residents of those states (each, a “Minimum Offering”). Unless otherwise defined herein, capitalized terms used herein shall have the respective meanings therefor as in the Dealer Manager Agreement.

In connection with the performance of the Dealer Manager’s obligations under Section 3 of the Dealer Manager Agreement, the Dealer Manager is authorized to retain the services of securities dealers (the “Dealer” and collectively, the “Dealers”) who are members of the Financial Industry Regulatory Authority (“FINRA”) to solicit subscriptions for Shares in connection with the Offering. You are hereby invited to become a Dealer and, as such, to use your best efforts to solicit subscribers for the Shares, in accordance with the following terms and conditions of this selected dealer agreement (this “Selected Dealer Agreement”):

A registration statement on Form N-2 (File No. 333-204659) with respect to the Shares, including a preliminary prospectus, has been prepared by the Company and was filed with the Securities and Exchange Commission (the “Commission”) on June 2, 2015, and was subsequently amended on July 17, 2015 and November 23, 2015, in accordance with the applicable requirements of the Securities Act of 1933, as amended (the “ Securities Act ”), the 1940 Act and the applicable rules and regulations of the Commission promulgated

thereunder (together with any applicable rules and regulations adopted under other relevant federal securities laws, the “SEC Rules and Regulations”). The Company has prepared and filed such amendments thereto and has amended the prospectus contained therein as may have been required to the date hereof, and will file such additional amendments and supplements thereto as may hereafter be required. The registration statement on Form N-2 and the prospectus contained therein, as finally amended at the date the registration statement is declared effective by the Commission (the “Effective Date”), and any registration statement filed under Rule 462 of the SEC Rules and Regulations, are respectively hereinafter referred to as the “Registration Statement” and the “Prospectus,” except that (i) if the Company files a post-effective amendment to such registration statement, then the term “Registration Statement” shall, from and after the declaration of the effectiveness of such post-effective amendment by the Commission, refer to such registration statement as amended by such post-effective amendment, and the term “Prospectus” shall refer to the amended prospectus then on file with the Commission, and (ii) if the prospectus filed by the Company pursuant to Rule 497 of the SEC Rules and Regulations shall differ from the prospectus on file at the time the Registration Statement or the most recent post-effective amendment thereto, if any, shall have become effective, then the term “Prospectus” shall refer to such prospectus filed pursuant Rule 497, as the case may be, from and after the date on which it shall have been filed. As used herein, the terms “Registration Statement,” “Preliminary Prospectus” and “Prospectus” shall include the documents, if any, incorporated by reference therein. As used herein, the term “Effective Date” also shall refer to the effective date of each post-effective amendment to the Registration Statement, unless the context otherwise requires.

The Dealer Manager and the Company have entered into that certain Dealer Manager Agreement dated [], 2015, in the form attached hereto as Exhibit “A.” By your execution and acceptance of this Selected Dealer Agreement, you will become one of the Dealers referred to in such Dealer Manager Agreement between the Company and the Dealer Manager and will be entitled and subject to the provisions contained in such Dealer Manager Agreement, including, but not limited to, the representations and warranties and the indemnifications contained in such Dealer Manger Agreement, including specifically the provisions of Section 5.4 of such Dealer Manager Agreement wherein each Dealer, upon the execution of this Selected Dealer Agreement, severally agrees to indemnify and hold harmless, among others, the Company, the Dealer Manager and each of their respective officers and directors, each person who has signed any of the Registration Statements and each person, if any, who controls the Company and the Dealer Manager within the meaning of Section 15 of the Securities Act or Section 20 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”) for the matters set forth in said Section 5.4 of the Dealer Manager Agreement. Such indemnification obligations shall survive the termination of this Selected Dealer Agreement and the Dealer Manager Agreement.

The Dealer hereby agrees to use its best efforts to sell the Shares for cash on the terms and conditions stated in the Prospectus. Nothing in this Selected Dealer Agreement shall be deemed or construed to make the Dealer an employee, agent, representative or partner of the Dealer Manager or of the Company, and Dealer is not authorized to act for the Dealer Manager or the Company or to make any representations except as set forth in the Prospectus and Authorized Sales Materials.

Those persons who purchase Shares will be instructed by the Dealer to make their checks payable to “HMS Income Fund, Inc.” or, in the alternative, may be given instructions for wiring funds to the appropriate account. Any Dealer receiving a check not conforming to the foregoing instructions shall return such check directly to such subscriber not later than the end of the next business day following its receipt. Checks received by the Dealer that conform to the foregoing instructions shall be transmitted for deposit pursuant to one of the methods in this Article III. Transmittal of received investor funds will be made in accordance with the following procedures:

Where, pursuant to the Dealer’s internal supervisory procedures, internal supervisory review is conducted at the same location at which subscription documents and checks are received from subscribers, checks will be transmitted by the end of the next business day following receipt by the Dealer to the Company for deposit in a segregated account until the Initial Closing or the next Periodic Closing has occurred or until the relevant Minimum Offering has been achieved, as applicable.

Where, pursuant to the Dealer’s internal supervisory procedures, final and internal supervisory review is conducted at a different location, checks will be transmitted by the end of the next business day following receipt by the Dealer to the office of the Dealer conducting such final internal supervisory review (the “Final Review Office”). The Final Review Office will in turn transmit by the end of the next business day following receipt at a different location by the Final Review Office such checks to the Company for deposit in a segregated account until the Initial Closing or the next Periodic Closing has occurred or until the relevant Minimum Offering has been achieved, as applicable.

Except as may be otherwise provided for in the “Plan of Distribution” section of the Prospectus, the Shares shall be offered to the public at the offering price set forth in the Prospectus. Except as otherwise indicated in the Prospectus or in any letter or memorandum sent to the Dealer by the Company or Dealer Manager, a minimum initial purchase of $2,500 in the Shares is required. Except as otherwise indicated in the Prospectus, additional investments may be made in minimum increments of at least $500. The Shares purchased are nonassessable.

Except for volume discounts described in the “Plan of Distribution” section of the Prospectus, which volume discounts shall be the responsibility of the Dealer to provide to investors who qualify, and except as otherwise provided in the “Plan of Distribution” section of the Prospectus, the Dealer’s selling commissions applicable to the Shares sold by the Dealer which it is authorized to sell hereunder is 7.0% of the gross proceeds of Shares sold by it in the Offering and accepted and confirmed by the Company, which commissions shall be payable by the Dealer Manager. For these purposes, Shares shall be deemed to be “sold” if and only if a transaction has closed with a subscriber for Shares pursuant to all applicable Offering and subscription

documents, the Company has accepted the subscription agreement of such subscriber, such Shares have been fully paid for and the Periodic Closing and the relevant Minimum Offering, if applicable, have occurred. The Dealer affirms that the Dealer Manager’s liability for commissions payable is limited solely to the proceeds of commissions receivable from the Company, and the Dealer hereby waives any and all rights to receive payment of commissions due until such time as the Dealer Manager is in receipt of the commissions from the Company. In addition, as set forth in the Prospectus, the Dealer Manager may, in its sole discretion, re-allow to Dealers participating in the Offering of Shares a portion of its dealer manager fee as a marketing fee, in an amount up to 1.5% of gross proceeds from the Shares sold in the Offering by such Dealer; and may pay out of its dealer manager fee up to an additional 1.0% of gross offering proceeds from the sale of Shares sold in the Offering by such Dealer, as reimbursement for distribution and marketing-related costs and expenses, including fees and costs associated with attending or sponsoring conferences and technology costs. The Company may also reimburse the Dealer Manager, which may in turn reimburse the Dealers, for bona fide out-of-pocket itemized and detailed due diligence expenses. The terms and conditions for payment of the fees and/or reimbursement arrangements shall be specified in Schedule I to this Selected Dealer Agreement. No dealer manager fee or selling commissions will be paid or re-allowed to any Dealer with respect to Shares issued and sold pursuant to the Company’s distribution reinvestment plan. The Dealer shall have the responsibility for disclosing to investors the terms of any such selling commissions, marketing fee or other reimbursement or payment provided to the Dealer Manager in connection therewith, if applicable and to the extent required.

The Company’s executive officers and directors and their immediate family members, as well as officers and employees of the Company’s advisers and their affiliates and their immediate family members (including spouses, parents, grandparents, children and siblings), Friends, and other individuals designated by the Company’s management, and, if approved by the Company’s board of directors, joint venture partners, consultants and other service providers, may purchase Shares in the Offering without being subject to any selling commissions or dealer manager fees. “Friends” mean those individuals who have had long standing business and/or personal relationships with the Company’s executive officers and directors.

The parties hereby agree that the foregoing commission is not in excess of the usual and customary distributors’ or sellers’ commission received in the sale of securities similar to the Shares, that Dealer’s interest in the Offering is limited to such commission from the Dealer Manager, the payments provided for on Schedule I to this Selected Dealer Agreement, if any, and the Dealer’s indemnity referred to in Section 5 of the Dealer Manager Agreement, and that the Company is not liable or responsible for such payments to the Dealer.

All orders, whether initial or additional, are subject to acceptance by and shall only become effective upon confirmation by the Company, which reserves the right to reject any order. Orders not accompanied by a subscription agreement and the required check or wire transfer in payment for the Shares may be rejected. Issuance of the Shares will be made only after actual receipt of payment therefor. If any check is not paid upon presentment, or if the Company is not in actual receipt of clearinghouse funds or cash, certified or cashier’s check or the equivalent in payment for the Shares, the Company reserves the right to cancel the sale without notice. In the event an order is rejected, canceled or rescinded for any reason, the Dealer agrees to return to the Dealer Manager any commission or other payment theretofore paid with respect to such order within 30 days thereafter and, failing to do so, the Dealer Manager shall have the right to offset amounts owed against future commissions or other payments due and payable to said Dealer. Notwithstanding anything else herein to the contrary, no commissions, payments or amounts whatsoever will be paid to the Dealer with respect to Shares subject to a Minimum Offering until such Minimum Offering has been achieved.

The Dealer Manager will inform the Dealer as to the jurisdictions in which the Dealer Manager has been advised by the Company that the Shares have been qualified for sale or are exempt under the respective securities or “blue sky” laws of such jurisdictions; but the Dealer Manager has not assumed and will not assume any obligation or responsibility as to the Dealer’s right to act as a broker and/or dealer with respect to the Shares in any such jurisdiction. The Dealer agrees that the Dealer will not make any offers or sell any Shares except in states in which the Dealer Manager may advise the Dealer that the Offering has been qualified or is exempt and in which the Dealer is legally qualified to make offers and further agrees to assure that each person to whom the Dealer sells Shares (at both the time of the initial purchase as well as at the time of any subsequent purchases) meets any special suitability standards which apply to sales in a particular jurisdiction, as described in the Blue Sky Survey (as defined below) and the subscription agreement. Neither the Dealer Manager nor the Company assume any obligation or responsibility in respect to the Dealer’s qualification to act as a broker and/or dealer with respect to the Shares in any jurisdiction. The blue sky survey which has been or will be furnished to the Dealer indicates the jurisdictions in which it is believed that the offer and sale of Shares covered by the Prospectus is exempt, or requires action under, the applicable blue sky or securities laws thereof, and what action, if any, has been taken with respect thereto (the “Blue Sky Survey”).

Prospectus or Authorized Sales Materials. The Dealer Manager will supply the Dealer with reasonable quantities of the Prospectus, any supplements thereto and any amended Prospectus, as well as any Authorized Sales Materials, for delivery to investors, and the Dealer will deliver a copy of the Prospectus and all supplements thereto and any amended Prospectus to each investor to whom an offer is made prior to or simultaneously with the first solicitation of an offer to sell the Shares to an investor. The Dealer agrees that it will not send or give Authorized Sales Materials to an investor unless it has previously sent or given a Prospectus to that investor or has simultaneously sent or given a Prospectus with such Authorized Sales Materials. The Dealer agrees that it will not show or give to any investor or prospective investor or reproduce any material or writing that is supplied to it by the Dealer Manager and marked “broker-dealer use only” or otherwise bearing a legend denoting that it is not to be used in connection with the sale of Shares to members of the public. The Dealer agrees that it will not use in connection with the offer or sale of Shares any material or writing supplied to it by the Company or the Dealer Manager bearing a legend stating that such material may not be used in connection with the offer or sale of the Shares or any other securities. The Dealer further agrees that it will not use in connection with the offer or sale of Shares any materials or writings which have not been previously authorized or approved by the Dealer Manager. The Dealer agrees to furnish a copy of any revised Preliminary Prospectus to each person to whom it has furnished a copy of any previous Preliminary Prospectus, and further agrees that it will itself mail or otherwise deliver all preliminary and final Prospectuses required for compliance with the provisions of Rule 15c2-8 under the Exchange Act. Regardless of the termination of this Selected Dealer Agreement, the Dealer will deliver a Prospectus in transactions in the Shares for a period of 90 days from the Effective Date of the Registration Statement or such longer period as may be required by the Exchange Act. On becoming a Dealer, and in offering and selling Shares, the Dealer agrees to comply with all the applicable requirements under the Securities Act and the Exchange Act.

A.The Dealer’s acceptance of this Selected Dealer Agreement constitutes a representation to the Company and the Dealer Manager that the Dealer is currently, and at all times while performing its functions under this Selected Dealer Agreement will be (a) duly organized, validly existing, and in good standing under the laws of the jurisdiction in which it was formed; (b) a properly registered broker-dealer under the Exchange Act; (c) duly licensed as a broker-dealer and authorized to sell Shares under Federal and state securities laws and regulations and in all states where it offers or sells Shares, and (d) a member in good standing of FINRA. This Selected Dealer Agreement shall automatically terminate if the Dealer (a) ceases to be a member in good standing of FINRA, (b) is subject to a FINRA suspension, or (c) its registration as a broker-dealer under the Exchange Act is terminated or suspended. The Dealer agrees to notify the Dealer Manager immediately in writing if the Dealer (a) ceases to be a member in good standing with FINRA, (b) is subject to a FINRA suspension, or (c) its registration as a broker-dealer under the Exchange Act is terminated or suspended. The Dealer hereby agrees to abide by all applicable FINRA rules.

The Dealer’s acceptance of this Selected Dealer Agreement constitutes a representation to the Company and the Dealer Manager that the Dealer has established and implemented an anti-money laundering compliance program and customer identification program (“AML Program”) in accordance with applicable FINRA rules, SEC Rules and Regulations and the Bank Secrecy Act, Title 31 U.S.C. Sections 5311-5355, as amended by the USA PATRIOT Act, and related regulations (31 C.F.R. Chapter X), specifically including, but not limited to, 31 U.S.C. 5318(h) (Anti-Money Laundering Programs) requiring financial institutions, including securities broker-dealers, to establish anti-money laundering programs reasonably expected to detect and cause the reporting of suspicious transactions in connection with the sale of Shares of the Company and 31 C.F.R. 1023.220 (Customer Identification Programs for broker-dealers) (the “AML Rules”). In addition, the Dealer represents that it has established and implemented a program for compliance with Executive Order 13224 and all regulations and programs administered by the Treasury Department’s Office of Foreign Assets Control (“OFAC” and such program is hereinafter referred to as the “OFAC Program”), and will continue to maintain its AML Program and OFAC Program consistent with AML Rules and OFAC requirements during the term of this Selected Dealer Agreement. Upon request by the Dealer Manager at any time, the Dealer hereby agrees to (a) furnish a copy of its AML Program and OFAC Program to the Dealer Manager for review, and (b) furnish a copy of the findings and any remedial actions taken in connection with the Dealer’s most recent independent testing of its AML Program and/or its OFAC Program.

The parties acknowledge that for the purposes of FINRA Rules, the investors who purchase Shares through the Dealer are “customers” of the Dealer and not the Dealer Manager. Nonetheless, to the extent that the Dealer Manager deems it prudent, the Dealer shall cooperate with the Dealer Manager’s reasonable requests for information, records and data related to the Company’s stockholders introduced to, and serviced by, the Dealer (the “Customers”). Notwithstanding the foregoing, the Dealer shall not be required to provide to the Dealer Manager any documentation that, in the Dealer’s reasonable judgment, would cause the Dealer to lose the benefit of attorney-client privilege or other privilege which it may be entitled to assert relating to the discoverability of documents in any civil or criminal proceedings. The Dealer hereby represents that it is currently in compliance with all AML Rules and all OFAC requirements, specifically including, but not limited to, the Customer Identification Program requirements under Section 326 of the USA PATRIOT Act. The Dealer hereby agrees, upon request by the Dealer Manager to (A) provide an annual certification to the Dealer Manager that, as of the date of such certification (i) its AML Program and its OFAC Program are consistent with the AML Rules and OFAC requirements; (ii) it has continued to implement its AML Program and its OFAC Program, and (iii) it is currently in compliance with all AML Rules and OFAC requirements, specifically including, but not limited to, the Customer Identification Program requirements under Section 326 of the USA PATRIOT Act; and (B) perform and carry out, on behalf of both the Dealer Manager and the

In offering Shares, the Dealer will make every reasonable effort to determine the purchase of the Shares is a suitable and appropriate investment for each purchaser of the Shares pursuant to a subscription agreement solicited by the Dealer and will comply with the requirements imposed upon it by the Prospectus, the Securities Act, the Exchange Act, applicable Blue Sky laws, and all applicable FINRA rules, as well as all other applicable rules and regulations relating to suitability of investors and prospectus delivery requirements, including without limitation, the Omnibus Guidelines of the North American Securities Administrators Association, Inc. Nothing contained in this Selected Dealer Agreement shall be construed to impose upon the Company or the Dealer Manager the responsibility of assuring that prospective investors meet the suitability standards set forth in the Prospectus, or to relieve the Dealer from the responsibility of assuring that prospective investors meet the suitability standards in accordance with the terms and provisions of this Prospectus.

The Dealer further represents, warrants and covenants to the Dealer Manager that neither the Dealer nor any person associated with the Dealer, shall offer or sell Shares in any jurisdiction except to investors who satisfy the investor suitability standards, including the minimum income and net worth standards and minimum investment requirements under the most restrictive of the following: (a) applicable provisions of the Prospectus; (b) applicable laws of the jurisdiction of which such investor is a resident; or (c) applicable FINRA rules. The Dealer agrees to ensure that, in recommending or otherwise facilitating the purchase, sale or exchange of Shares to an investor, the Dealer, or any person associated with the Dealer, shall have reasonable grounds to believe, on the basis of information obtained from the investor (and thereafter maintained in the manner and for the period provided in such Rules) concerning his age, investment objectives, investment experience, income, net worth, other investments, financial situation and needs, and any other information known to the Dealer, or person associated with the Dealer, that (a) the investor is in a financial position appropriate to enable him to benefit from an investment in the Shares based upon the investor’s overall investment objectives and overall portfolio structure; (b) the investor is able to bear the economic risk inherent in an investment in Shares in the amount proposed based on the investor’s overall financial situation; (c) that the investor has an apparent understanding of the fundamental risks of an investment in Shares, the risk that the investor may lose the entire investment, the lack of liquidity of the Shares, the background and qualifications of the Sponsor or the advisers to the Company, and the tax consequences of an investment in the Shares; and (d) an investment in Shares is otherwise suitable for such investor. The Dealer further represents, warrants and covenants that the Dealer, or a person associated with the Dealer, will make every reasonable effort to determine the suitability and appropriateness of an investment in Shares of each proposed

investor by reviewing documents and records disclosing the basis upon which the determination as to suitability was reached as to each purchaser of Shares pursuant to a subscription solicited by the Dealer, whether such documents and records relate to accounts which have been closed, accounts which are currently maintained, or accounts hereafter established. The Dealer agrees to retain such documents and records in the Dealer’s records for a period not less than that required in order to comply with all applicable federal, state and other statutory and regulatory requirements and to make such documents and records available to (a) the Dealer Manager and the Company upon request, and (b) to representatives of the Commission , FINRA and applicable state securities administrators upon the Dealer’s receipt of an appropriate request for documents from any such agency. The Dealer shall not purchase any Shares for a discretionary account without obtaining the prior written approval of the Dealer’s Customer and his or her signature on a subscription agreement.

Prior to offering the Shares for sale, the Dealer shall have conducted an inquiry such that the Dealer has reasonable grounds to believe, based on information made available to the Dealer by the Company or the Dealer Manager through the Prospectus or other materials, that all material facts are adequately and accurately disclosed and provide a basis for evaluating a purchase of Shares. In determining the adequacy of disclosed facts pursuant to the foregoing, each Dealer may obtain, upon request, information on material facts relating at a minimum to the following: (a) items of compensation; (b) assets; (c) tax aspects; (d) financial stability and experience of the Company and its advisers; (e) conflicts and risk factors; and (f) appraisals and other pertinent reports.

Notwithstanding the foregoing, each Dealer may rely upon the results of an inquiry conducted by an independent third party retained for that purpose or another Dealer, provided that: (a) such Dealer has reasonable grounds to believe that such inquiry was conducted with due care by said independent third party or such other Dealer; (b) the results of the inquiry were provided to the Dealer with the consent of the other Dealer conducting or directing the inquiry; and (c) no Dealer that participated in the inquiry is an affiliate of the Company.

This Selected Dealer Agreement shall become effective upon the execution hereof by the Dealer and receipt of such executed Selected Dealer Agreement by the Dealer Manager; provided, however, that in the event of the execution of this Selected Dealer Agreement prior to the time that the Registration Statement becomes effective with the Commission , this Selected Dealer Agreement shall not become effective prior to the Registration Statement becoming effective with the Commission and shall instead become effective simultaneously with the effectiveness of the Registration Statement.

The Dealer will immediately suspend or terminate its offer and sale of Shares upon the request of the Company or the Dealer Manager at any time and will resume its offer and sale of Shares hereunder upon subsequent request of the Company or the Dealer Manager. The Dealer Manager or the Dealer may terminate this Selected Dealer Agreement by written notice. Such termination shall be effective 48 hours after the mailing of such notice. This Selected Dealer Agreement and the exhibits and schedules hereto shall constitute the entire agreement of the parties and shall supersede all prior agreements, if any, between the parties hereto.

Nothing in this Selected Dealer Agreement shall be construed or interpreted to constitute the Dealer as an employee, agent or representative of, or in association with or in partnership with, the Dealer Manager, the Company or the other Dealers; instead, this Selected Dealer Agreement shall only constitute the Dealer as a dealer authorized by the Dealer Manager to sell the Shares according to the terms set forth in the Registration Statement and the Prospectus as amended and supplemented and in this Selected Dealer Agreement.

I have read the foregoing Selected Dealer Agreement and I hereby accept and agree to the terms and conditions therein set forth. I hereby represent that the list below of jurisdictions in which I am registered or licensed as a broker or dealer and am fully authorized to sell securities is true and correct, and that the Errors and Omissions Insurance information set forth below is true and accurate, and I agree to advise you of any changes to the information listed on this signature page during the term of this Selected Dealer Agreement.



Name:
Type of entity:
	(to be completed by the Dealer)
	(corporation, partnership or proprietorship)
Organized in the State of:
	(to be completed by the Dealer)
	(State)
Licensed as broker-dealer in the following States:
	(to be completed by the Dealer)
Tax I.D. #:



Name:
Company:
Address:
City, State and Zip Code:
Telephone ( ) No.:
Telefax ( ) No.:




	(Dealer’s Firm Name)
By:
	Signature

	(Please Print)

	Title

	Date



Name of Insurance Company:

Amount of E&O Insurance:

Policy Number:


1.	Identity of the Dealer:


3.	Person to receive notice pursuant to Section XVIII: