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KENTUCKY THOROUGHBRED BREEDERS INCENTIVE FUND AUTHORIZED AGENT FORM KENTUCKY HORSE RACING COMMISSION 4063 Ironworks Parkway Building B Lexington KY 40511 Phone 859-246-2847 Fax 859-246-2887 www. Khrc.ky. gov This form cannot be altered without the written consent of the agent and the KHRC. Date 20 AGENT INFORMATION To the Kentucky Horse Racing Commission I have this day appointed Print Name of Agent Print Associated Farm if Applicable Street City Phone Number Fax Number State Zip E-Mail Address to act for me in the application for the Kentucky Thoroughbred Breeders Incentive Fund KBIF for the period indicated below. Said appointee as my duly appointed and authorized agent shall have full power and authority to act for me in any and all matters and to execute any and all documents in connection with or arising out of the application to said KBIF. I understand that the KBIF requires that in order for the mare to qualify she must remain in the Commonwealth of Kentucky from the first cover until foaling. khrc*ky. gov This form cannot be altered without the written consent of the agent and the KHRC. Date 20 AGENT INFORMATION To the Kentucky Horse Racing Commission I have this day appointed Print Name of Agent Print Associated Farm if Applicable Street City Phone Number Fax Number State Zip E-Mail Address to act for me in the application for the Kentucky Thoroughbred Breeders Incentive Fund KBIF for the period indicated below. Said appointee as my duly appointed and authorized agent shall have full power and authority to act for me in any and all matters and to execute any and all documents in connection with or arising out of the application to said KBIF* I understand that the KBIF requires that in order for the mare to qualify she must remain in the Commonwealth of Kentucky from the first cover until foaling. I further understand that the representations of my agent may subject me to penalties under Section 9 of 810 KAR 1 070 if an application is filed for a mare that is proved to be ineligible due to false or misleading information provided on the application which is not corrected or if there is a knowing violation of the administrative regulation* Penalties include but are not limited to 1 the denial or revocation of the registration 2 being forever barred from registering foals for the KBIF and 3 civil and criminal penalties under the laws of the Commonwealth of the Kentucky for providing fraudulent information* THIS AGENCY DESIGNATION IS REVOCABLE ONLY IN WRITING* The duration of agency shall be for the breeding year of the date above unless otherwise indicated here Through and including applications for the breeding year date 20 Initials Print Name of Breeder Signature of Breeder The foregoing instrument was acknowledged before me on the day of 20 Name of Breeder My commission expires 20 Signature of Notary Public. Said appointee as my duly appointed and authorized agent shall have full power and authority to act for me in any and all matters and to execute any and all documents in connection with or arising out of the application to said KBIF* I understand that the KBIF requires that in order for the mare to qualify she must remain in the Commonwealth of Kentucky from the first cover until foaling. I further understand that the representations of my agent may subject me to penalties under Section 9 of 810 KAR 1 070 if an application is filed for a mare that is proved to be ineligible due to false or misleading information provided on the application which is not corrected or if there is a knowing violation of the administrative regulation* Penalties include but are not limited to 1 the denial or revocation of the registration 2 being forever barred from registering foals for the KBIF and 3 civil and criminal penalties under the laws of the Commonwealth of the Kentucky for providing fraudulent information* THIS AGENCY DESIGNATION IS REVOCABLE ONLY IN WRITING* The duration of agency shall be for the breeding year of the date above unless otherwise indicated here Through and including applications for the breeding year date 20 Initials Print Name of Breeder Signature of Breeder The foregoing instrument was acknowledged before me on the day of 20 Name of Breeder My commission expires 20 Signature of Notary Public.