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VITS FOR BRITISH COLUMBIA DATE: (Y Y Y Y /M M /D D ) 1 o lH lo c r/c F f 5 ,c 1am acting as my own Financial Agent ....................................... r t'/ 1have appointed as my Financial Agent V " C iv n e raA NOMINEE'S SIGNATURE ORIGINAL - C ity o f N a n a im o PLEASE KEEP A COPY FOR YOUR RECORDS FINANCIAL AGENT'S NAME (IF APPLICABLE) C2 - P age 2 o f 2 This f o r m is a v a ila b le fo r p u b lic in s p e c tio n d b British Statement of Disclosure -*!p- COLUMBI.

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