GTV传媒集团公平基金索赔证明表（索赔截止日：2022年6月6日）中英对照全文

GTV传媒集团公平基金 由JND Legal Administration转交 91403号邮政信箱 华盛顿州西雅图市，邮政编码98111

GTV Media Group Fair Fund c/o JND Legal Administration PO Box 91403 Seattle, WA 98111

免费电话：866-853-5013 分配网站：www.GTVMediaGroupFairFund.com 电子邮箱：[email protected]

Toll-Free Number: 866-853-5013 Distribution Website: www.GTVMediaGroupFairFund.com Email: [email protected]

GTV传媒集团公平基金是在GTV Media Group, Inc.、Saraca Media Group, Inc.及Voice of Guo Media, Inc.一案中设立的。如需接受从该基金获得分配款的资格审查，您必须填写并签署本索赔证明表（“索赔表”），附上全部必要证明文件，一并提交给JND Legal Administration（“基金管理人”）。

To be considered for eligibility for a distribution payment from the GTV Media Group Fair Fund, created In the Matter of GTV Media Group, Inc., Saraca Media Group, Inc., and Voice of Guo Media, Inc., you must complete and sign this Proof of Claim Form (“Claim Form”), include all necessary documentation, and submit the package to JND Legal Administration (the “Fund Administrator”).

您可通过分配网站在线提交，最迟须于2022年6月6日太平洋标准时间（PST）晚上11:59完成；也可通过美国一类邮件（First Class Mail）寄送，邮戳日期不得晚于2022年6月6日；如采用美国一类邮件以外的方式，则须于2022年6月6日或之前送达基金管理人。

Submissions may be made online through the Distribution Website no later than 11:59 p.m. PST on June 6, 2022; by First Class Mail postmarked by June 6, 2022; or if not by First Class mail, received by the Fund Administrator by June 6, 2022.

“索赔截止日”载于分配方案。

The “Claims Bar Date” is identified in the Distribution Plan.

未能在2022年6月6日或之前提交索赔表，可能导致您的索赔被驳回，并可能使您无资格从GTV传媒集团公平基金获得任何款项。

Failure to submit your Claim Form by June 6, 2022, may result in your claim being rejected and may preclude you from being eligible to recover any money from the GTV Media Group Fair Fund.

您必须按照本表中的说明提交索赔表。

Your Claim Form must be submitted in compliance with the directions herein.

02 一般说明 04 第I部分——索赔人身份资料 05 第II(A)部分及第II(B)部分——交易明细表 07 收款方式选择表 08 证明与签名 10 核对清单 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

02 GENERAL INSTRUCTIONS 04 Part I - CLAIMANT IDENTIFICATION 05 Part II(A) and Part II(B) - SCHEDULES OF TRANSACTIONS 07 PAYMENT ELECTION FORM 08 CERTIFICATION AND SIGNATURE 10 REMINDER CHECKLIST Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

1. 如您是代表投资者募集资金并希望提出索赔的第三方，必须遵守www.GTVMediaGroupFairFund.com网站“重要文件”栏目中的《电子申报说明》。

1. If you are a third party who solicited funds on behalf of investors and are wishing to file a claim, you must follow the Electronic Filing Instructions found on the website www.GTVMediaGroupFairFund.com under “Important Documents”.

凡未按规定的电子申报格式提交的文件，均可能被拒收。

Any file not submitted in accordance with the required electronic filing format will be subject to rejection.

2. 您必须按www.GTVMediaGroupFairFund.com的指示，最迟于索赔截止日太平洋标准时间（PST）晚上11:59在线提交填写完整并已签署的索赔表及充分的证明文件；或者通过美国一类邮件寄送，邮戳日期不得晚于索赔截止日；如采用美国一类邮件以外的方式寄送，则须于索赔截止日或之前送达基金管理人。

2. Your completed and signed Claim Form, including adequate supporting documentation, must be submitted online no later than 11:59 p.m. PST on the Claims Bar Date, following the directions at www.GTVMediaGroupFairFund.com; or, alternatively, sent by First Class Mail, postmarked no later than the Claims Bar Date or, if not sent by First Class Mail, received by the Fund Administrator no later than the Claims Bar Date.

3. 您必须填报第II(A)部分及第II(B)部分交易明细表（第6、7页）所要求的全部交易，并由您和／或您的代表完整填写本索赔表。

3. You must include all your transactions requested in Parts II(A) and II(B), the Schedules of Transactions (pages 6 and 7), and you and/or your representative must fully complete this Claim Form.

索赔表必须由符合条件的证券的实益拥有人（见下文第9段）或其代表签署，虚假陈述须承担伪证责任。

The Claim Form must be signed by the beneficial owner of the eligible Security (see paragraph 9, below) or by their representative, under the penalty of perjury.

如未完整填写并签署索赔表，或未附上充分的证明文件，您的索赔可能被驳回，且您可能无法从GTV传媒集团公平基金获得任何款项。

If you fail to complete and sign the Claim Form, including adequate supporting documentation, your claim may be rejected, and you may be precluded from any recovery from the GTV Media Group Fair Fund.

4. 请勿在索赔表或任何证明文件上使用荧光笔。

4. DO NOT use highlighter on the Claim Form or any supportive documents.

5. 提交索赔表并不保证您有资格获得分配款；资格将依据已获批准的方案所列标准确定，该方案可在www.GTVMediaGroupFairFund.com查阅及下载。

5. Submission of the Claim Form does not guarantee that you will be eligible for a Distribution Payment; eligibility will be determined in accordance with the criteria in the approved Plan, available for review and download at www.GTVMediaGroupFairFund.com.

6. 索赔表提交方式： (a) 在线提交：须按www.GTVMediaGroupFairFund.com的指示，最迟于索赔截止日太平洋标准时间（PST）晚上11:59完成在线提交；

6. Claim Form Submission: (a) Online: Online submissions must be completed no later than 11:59 p.m. PST on the Claims Bar Date, following the directions at www.GTVMediaGroupFairFund.com;

(b) 美国一类邮件或其他递送方式：通过美国一类邮件提交的，邮戳日期不得晚于索赔截止日；通过其他递送服务提交的，必须于索赔截止日或之前送达基金管理人。

(b) First Class Mail or other Delivery: Submissions by First Class Mail must be postmarked no later than the Claims Bar Date; submissions by other delivery service must be RECEIVED by the Fund Administrator no later than the Claims Bar Date.

除非您提交的索赔表带有美国邮政邮戳，否则以基金管理人实际收到之时视为提交时间。

Unless your Claim Form is submitted with a U.S. Mail postmark, it will be deemed to have been submitted when actually received by the Fund Administrator.

您必须将填写完整并已签署的索赔表连同充分的证明文件寄送至以下地址： GTV传媒集团公平基金 由JND Legal Administration转交 91403号邮政信箱 华盛顿州西雅图市，邮政编码98111

You must send your completed and signed Claim Form, with adequate supporting documentation, to the address below: GTV Media Group Fair Fund c/o JND Legal Administration PO Box 91403 Seattle, WA 98111

(c) 您有责任依照本表的说明，及时提交填写完整并已签署的索赔表及充分的证明文件，并且必须能够以文件证明您已及时、适当、完整地提交材料。

(c) It is your responsibility to timely submit your completed and signed Claim Form and adequate supporting documentation in accordance with the directions herein and you must be able to document timely, proper, and complete submission.

7. 请使用本索赔表第II部分（第6、7页）的交易明细表，提供您就每种符合条件的证券进行的交易（包括无偿转让和交付）及所持证券的全部必要详情。

7. Use the Schedules of Transactions in Part II of this Claim Form, pages 6 and 7, to supply all required details of your transaction(s) (including free transfers and deliveries) and holdings of each eligible Security.

无论相关交易产生盈利还是亏损，均须在明细表中提供有关您持有、购买、取得及出售符合条件的证券的全部所需信息。

On these schedules, please provide all of the requested information with respect to your holdings, purchases, acquisitions, and sales of the eligible Security, regardless of whether such transactions resulted in a profit or a loss.

未报告指定相关期间内的全部交易及持有情况，可能导致您的索赔被驳回。

Failure to report all transaction and holding information during the requested Relevant Period may result in the rejection of your claim.

2 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

2 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

G实体的证券及相应相关期间（含起止日） 证券｜相关期间开始日期｜相关期间结束日期 GTV普通股｜2020年4月20日｜2020年6月2日 数字资产：G-Coins或G-Dollars｜2020年4月1日｜2020年6月30日

The G-Entities Security and Corresponding Relevant Period(s) (Inclusive) Security Relevant Period Start Date Relevant Period End Date GTV Common Stock 4/20/2020 6/2/2020 Digital Assets: G-Coins or G-Dollars 4/1/2020 6/30/2020

8. 您必须就本索赔表所报告的交易提交证明文件，例如通过支票、电汇付款的凭证、认购协议或其他类似文件。

8. You must submit supporting documentation for the transactions reported on this Claim Form, such as proof of your payment via check, wire, subscription agreement, or other similar documents.

如您未持有上述文件，请向您的银行或其他账户代表索取副本或同等证明文件。

If such documents are not in your possession, please obtain copies or equivalent documents from your bank or other account representative.

未提供上述文件可能导致您的索赔被驳回。

Failure to supply this documentation may result in the rejection of your claim.

请勿寄送文件原件。

DO NOT SEND ORIGINAL DOCUMENTS.

请留存您向基金管理人提交的全部文件的副本。

Please keep a copy of all documents that you send to the Fund Administrator.

此外，请勿在索赔表或任何证明文件的任何部分使用荧光笔。

Also, please do not highlight any portion of the Claim Form or any supporting documents.

9. 各独立法律主体应分别提交索赔表（即个人账户、联名账户、个人退休账户、为未成年人持有的账户等，应分别提交索赔表）。

9. Separate Claim Forms should be submitted for each separate legal entity (i.e. a separate Claim Form should be filed for an individual account, a joint account, an IRA account, an account held for minor, etc.).

反之，同一法律主体无论拥有多少个独立账户，均应以一份索赔表填报该主体进行的全部交易（例如，拥有多个证券经纪账户的公司应在同一份索赔表中填报其所有账户的全部交易；个人以同一姓名开立多个账户的，也应如此）。

Conversely, a single Claim Form should be submitted on behalf of one legal entity that includes all transactions made by that entity, no matter how many separate accounts that entity has (e.g., a corporation with multiple brokerage accounts should include all transactions made in all accounts on one Claim Form, as should an individual with multiple accounts maintained in his or her same name).

10. 如您在相应相关期间内购买或以其他方式取得符合条件的证券，并以本人名义持有股票，则您既是实益拥有人，也是登记拥有人；您必须签署本索赔表，方可接受参与GTV传媒集团公平基金分配的资格审查。

10. If you purchased or otherwise acquired an eligible Security during the corresponding Relevant Period(s) and held the stock in your name, you are the beneficial owner as well as the record owner and you must sign this Claim Form to be considered for participation in the GTV Media Group Fair Fund.

共同实益拥有人必须各自签署本索赔表，且各自姓名必须列于本索赔表第I部分。

Joint beneficial owners must each sign this Claim Form and their names must appear in Part I of this Claim Form.

如您在相应相关期间内为自身利益购买或以其他方式取得符合条件的证券，但股票登记在代名持有人或证券经纪公司等第三方名下，则您仍是该等股份的实益拥有人，而第三方为登记拥有人。

If you purchased or otherwise acquired an eligible Security during the corresponding Relevant Period(s) for your own benefit, but the stock was registered in the name of a third party, such as a nominee or brokerage firm, you are still the beneficial owner of these shares, but the third party is the record owner.

必须由实益拥有人而非登记拥有人签署本索赔表，方可接受从GTV传媒集团公平基金获得分配款的资格审查。

The beneficial owner, not the record owner, must sign this Claim Form to be considered for eligibility for a distribution payment from the GTV Media Group Fair Fund.

11. 代理人、遗嘱执行人、遗产管理人、监护人及受托人必须代表其所代理的个人和实体填写并签署索赔表，且必须： (a) 明确说明其行事身份； (b) 列明符合条件的证券的实益拥有人（或其就该证券所代表的其他个人或实体）的姓名或名称、账号、社会保障号码（或纳税人识别号码）、地址及电话号码；以及 (c) 提供有权代表实益拥有人提交索赔表的证明（证券经纪人仅证明其有权自行决定在他人或其他实体账户中买卖证券，并不足以证明其有权填写并签署索赔表）。

11. Agents, executors, administrators, guardians, and trustees must complete and sign the Claim Form on behalf of persons and entities represented by them, and they must: (a) expressly state the capacity in which they are acting; (b) identify the name, account number, Social Security Number (or taxpayer identification number), address and telephone number of the beneficial owner of (or other person or entity on whose behalf they are acting with respect to) the eligible Security; and (c) furnish evidence of their authority to submit the Claim Form on behalf the beneficial owner (Authority to complete and sign a Claim Form cannot be established by stockbrokers demonstrating only that they have discretionary authority to trade securities in another person/entity’s accounts.)

12. 提交本索赔表，即表示您请求对您参与GTV传媒集团公平基金分配的资格作出认定。

12. By submitting this Claim Form, you will be seeking a determination of your eligibility to participate in the distribution of the GTV Media Group Fair Fund.

如您并非潜在索赔人（定义见分配方案第25段），或属于排除对象（见方案第16段），请勿提交索赔表。

If you are NOT a Potential Claimant (as defined in the Plan of Distribution, paragraph 25), or are an Excluded Party (Plan, paragraph 16), DO NOT submit a Claim Form.

13. 如对索赔表有疑问，或需索赔表或方案通知的额外副本，您可致函上述地址联系基金管理人，拨打免费热线866-853-5013，发送电子邮件至[email protected]，或从www.GTVMediaGroupFairFund.com下载文件。

13. If you have questions concerning the Claim Form or need additional copies of the Claim Form or the Plan Notice, you may contact the Fund Administrator by writing to the above address, by calling the toll-free hotline at 866-853-5013, by sending an email to [email protected], or you may download the documents from www.GTVMediaGroupFairFund.com.

请注意：您只有收到确认电子邮件，才能确认索赔已经提交。

PLEASE NOTE: YOUR CLAIM IS NOT CONFIRMED AS SUBMITTED UNTIL YOU RECEIVE AN ACKNOWLEDGEMENT EMAIL.

基金管理人将在收到您的索赔表后60日内，以电子邮件确认收件。

THE FUND ADMINISTRATOR WILL ACKNOWLEDGE RECEIPT OF YOUR CLAIM FORM BY EMAIL WITHIN 60 DAYS OF RECEIPT.

如您在60日内未收到确认电子邮件，请联系基金管理人。

IF YOU DO NOT RECEIVE AN ACKNOWLEDGEMENT EMAIL WITHIN 60 DAYS, PLEASE CONTACT THE FUND ADMINISTRATOR.

3 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

3 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

基金管理人将使用下列资料，就本索赔表的所有事项与您联系。

The Fund Administrator will use the information supplied below for all communications regarding this Claim Form.

如资料有变，您必须及时致函上文第6段所列地址，或发送电子邮件至[email protected]，通知基金管理人。

If this information changes, you MUST promptly notify the Fund Administrator in writing at the address in paragraph 6, above, or by email to [email protected].

必须提供所有个人和实体的完整姓名或名称。

Complete names of all persons and entities must be provided.

实益拥有人姓名或名称

Beneficial Owner Name

共同实益拥有人姓名或名称

Joint Beneficial Owner Name

代表姓名或名称（如适用，例如遗嘱执行人、遗产管理人、受托人、转交人等；如与实益拥有人不同） 请注意：如您是代表投资者申报的第三方，必须遵守基金网站所载《电子申报说明》。

Name of Representative, if applicable (e.g., executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Please note: If you are a third party filing on behalf of investors, you must follow the Electronic Filing Instructions found on the Fund Website.

街道地址

Street Address

城市｜州／省｜邮政编码

City State/Province Zip Code

外国邮政编码（如适用）｜美国以外的国家（如适用）

Foreign Postal Code (if applicable) Foreign Country (if applicable)

电话号码（日间）｜电话号码（晚间） ―　―｜―　―

Telephone Number (Day) Telephone Number (Evening) ― ― ― ―

电子邮箱（请注意：提供电子邮箱即表示您授权基金管理人使用该邮箱向您提供与本项索赔有关的信息）

Email Address (Please note by providing your email, you authorize the Fund Administrator to use it in providing you with information relevant to this claim)

社会保障号码／纳税人识别号码末4位｜身份证件类型及号码（驾驶执照、护照、签证或其他政府签发的身份证件）

Last Four of SSN/TAX ID # Identification Type and Number (Driver’s License, Passport, Visa, or other government-issued ID)

4 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

4 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

请务必按上文一般说明的详细要求，随索赔表附上适当的证明文件。

Please be sure to include proper documentation with your Claim Form as described in detail in the General Instructions above.

请勿在本明细表中填报GTV普通股以外的证券信息。

Do not include information regarding securities other than GTV common stock on this schedule.

1. 2020年4月20日至2020年6月2日（含起止日）期间购买／取得的GTV普通股——逐笔列明该期间内的每一笔购买／取得交易。

1. PURCHASES/ACQUISITIONS OF GTV COMMON STOCK DURING THE PERIOD FROM APRIL 20, 2020 THROUGH AND INCLUDING JUNE 2, 2020 – Separately list each and every purchase/acquisition during this period.

（必须附证明文件。）

(Must be documented.)

购买／取得日期（按时间顺序列示）（月／日／年）｜购买／取得股数｜每股购买／取得价格｜购买／取得总价（不含任何费用、税款及佣金）｜是否附有购买／取得证明

Date of Purchase/ Total Purchase/ Acquisition Proof of Purchase/ Acquisition Enclosed Number of Shares Purchase/ Acquisition (List Price Purchased/ Acquisition Chronologically) (excluding all fees, taxes, Acquired Price Per Share (Month/Day/Year) and commissions)

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

2. 2020年4月20日至2020年7月1日（含起止日）期间GTV普通股的退款或出售——逐笔列明该期间内的每一笔出售或退款／处置交易。（必须附证明文件。）如无，请在此勾选 退款／出售日期（按时间顺序列示）（月／日／年）｜退款／出售股数｜每股退款／出售价格｜退款／出售总价（不含任何费用、税款及佣金）｜退款实体名称｜是否附有退款或出售证明

2. REFUND OR SALES OF GTV COMMON STOCK DURING THE PERIOD FROM APRIL 20, 2020 THROUGH AND INCLUDING JULY 1, 2020 – Separately list each and every IF NONE, CHECK HERE SALE OR REFUND/disposition during this period. (Must be documented.) Date of Refund/Sale Number of Total Refund/Sale Price Name of Refund Proof of Refund or Refund/Sale Price (List Chronologically) Shares (excluding all fees, taxes, Entity Sale Per Share (Month/Day/Year) Refunded/Sold and commissions) Enclosed

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

3. 期末持有情况——请填写截至2020年7月1日交易结束时所持GTV普通股的投资总额（以美元计）。（必须附证明文件。）如无，请填写“zero”或“0”。金额｜是否附有持仓证明 是　否

3. ENDING HOLDINGS – State the total dollar amount invested in GTV common stock held as Amount Proof of Position of the close of trading on JULY 1, 2020. (Must be documented.) If none, write “zero” or “0.” Enclosed Y N

如上述明细表不够填写，请按相同格式附加明细表。

IF YOU REQUIRE ADDITIONAL SPACE FOR THE SCHEDULE ABOVE, ATTACH EXTRA SCHEDULES IN THE SAME FORMAT.

请在每张附页上以正楷填写实益拥有人的完整姓名或名称、社会保障号码／纳税人识别号码末4位及具体证券名称。

PRINT THE BENEFICIAL OWNER’S FULL NAME AND LAST FOUR DIGITS OF SOCIAL SECURITY/TAXPAYER IDENTIFICATION NUMBER, AND THE SPECIFIC SECURITY ON EACH ADDITIONAL PAGE.

如附有额外明细表，请勾选此框。

IF YOU DO ATTACH EXTRA SCHEDULES, CHECK THIS BOX.

如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

请务必按上文一般说明的详细要求，随索赔表附上适当的证明文件。

Please be sure to include proper documentation with your Claim Form as described in detail in the General Instructions above.

请勿填报名为G-Coins或G-Dollars的“数字资产”以外的证券信息。

Do not include information regarding securities other than “DIGITAL ASSETS" KNOWN AS EITHER G-COINS OR G-DOLLARS.

1. 2020年4月1日至2020年6月30日（含起止日）期间购买名为G-Coins或G-Dollars的“数字资产”／为该等资产付款的情况——逐笔列明该期间内的每一笔购买／取得交易。

1. PURCHASES/PAYMENTS FOR “DIGITAL ASSETS" KNOWN AS EITHER G-COINS OR G-DOLLARS DURING THE PERIOD FROM APRIL 1, 2020 THROUGH AND INCLUDING JUNE 30, 2020 – Separately list each and every purchase/acquisition during this period.

（必须附证明文件。）

(Must be documented.)

购买／取得日期（按时间顺序列示）（月／日／年）｜购买／取得的数字资产数量｜每单位数字资产的购买／取得价格｜购买／取得总价（不含任何费用、税款及佣金）｜该笔购买是否已退款？是否附有购买／取得证明 ／　／｜美元｜美元｜是　否

Purchase/ Total Purchase/ Was This Purchase Refunded? Date of Purchase/ Acquisition Number of Digital Acquisition Acquisition Price Proof of Purchase/ Acquisition Enclosed (List Chronologically) Assets Purchased/ Price Per Digital (excluding all fees, taxes, (Month/Day/Year) Acquired Asset and commissions) / / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

2. 2020年4月1日至2020年7月1日（含起止日）期间名为G-Coins或G-Dollars的“数字资产”的退款或出售——逐笔列明该期间内的每一笔出售或退款／处置交易。（必须附证明文件。）如无，请在此勾选 退款／出售日期（按时间顺序列示）（月／日／年）｜退款／出售的数字资产数量｜每单位数字资产的退款／出售价格｜退款／出售总价（不含任何费用、税款及佣金）｜退款实体名称｜是否附有退款或出售证明 ／　／｜美元｜美元｜是　否

2. REFUND OR SALES OF “DIGITAL ASSETS" KNOWN AS EITHER G-COINS OR G-DOLLARS DURING THE PERIOD FROM APRIL 1, 2020 THROUGH AND INCLUDING JULY 1, 2020 – IF NONE, CHECK HERE Separately list each and every SALE OR REFUND/disposition during this period. (Must be documented.) Date of Refund/Sale Number of Total Refund/Sale Price Name of Refund Proof of Refund or Refund/Sale Price (List Chronologically) Digital Assets (excluding all fees, taxes, Entity Sale Per Digital Asset (Month/Day/Year) Refunded/Sold and commissions) Enclosed / / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

／　／｜美元｜美元｜是　否

/ / $ $ Y N

3. 期末持有情况——请填写截至2020年7月1日交易结束时所持G-Coins或G-Dollars的投资总额（以美元计）。（必须附证明文件。）如无，请填写“zero”或“0”。金额｜是否附有持仓证明 是　否

3. ENDING HOLDINGS – State the total dollar amount invested in G-COINS OR G-DOLLARS held Amount Proof of Position as of the close of trading on JULY 1, 2020. (Must be documented.) If none, write “zero” or “0.” Enclosed Y N

如上述明细表不够填写，请按相同格式附加明细表。

IF YOU REQUIRE ADDITIONAL SPACE FOR THE SCHEDULE ABOVE, ATTACH EXTRA SCHEDULES IN THE SAME FORMAT.

请在每张附页上以正楷填写实益拥有人的完整姓名或名称、社会保障号码／纳税人识别号码末4位及具体证券名称。

PRINT THE BENEFICIAL OWNER’S FULL NAME AND LAST FOUR DIGITS OF SOCIAL SECURITY/TAXPAYER IDENTIFICATION NUMBER, AND THE SPECIFIC SECURITY ON EACH ADDITIONAL PAGE.

如附有额外明细表，请勾选此框。

IF YOU DO ATTACH EXTRA SCHEDULES, CHECK THIS BOX.

6 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

6 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

如希望通过支票收取可能获得的款项，请填写本栏。

Complete this section if you want to receive any potential payment via Check.

姓名或名称

Name

支票上显示的姓名或名称及地址： 街道 城市｜州｜邮政编码｜国家

Name and Address to Street Appear on Checks: City State Zip Country

如希望通过电汇收取可能获得的款项，请填写本栏*。

Complete this section if you want to receive any potential payment via wire*.

您是否为账户持有人？　是　否

Are you the account holder? Yes No

注意：如您获得分配款并将款项转给另一方，您可能须接受核验，并可能被第三方收取费用。

NOTE: If you are receiving a distribution payment and you send your funds to a different party, you may be subject to a verification process and may incur fees from a third party.

请勾选此框，确认已理解上述内容

Check box to confirm understanding

联系信息：

Contact Information:

银行名称：

Bank Name:

银行ABA号码／路由号码：

Bank ABA/Routing Number:

银行地址：

Bank Address:

银行SWIFT代码（国际汇款适用）：

Bank SWIFT Code (if Int’l):

中间行名称（如有）：

Intermediary Bank Name (if any):

中间行：

Intermediary Bank:

账号：

Account #:

账户名称：

Name of Account:

收款人地址：

Recipient Address:

是否有第二账户？（是／否） 第二账户路由号码：

Secondary Account? (Y/N) Secondary Account Routing Number:

第二账户账号：

Secondary Account Number:

特别指示备注：

Special Instructions Note:

其他银行信息：

Other Bank Information:

如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

下列签署人声明并证明以下事项，如有虚假，愿承担伪证责任： 1. 本人不属于： (a) 被申请人； (b) 被申请人的现任或前任高级管理人员或董事，或上述任何个人或实体的受让人、债权人、继承人、遗产受分配人、配偶、父母、受抚养子女或受其控制的实体； (c) 因与命令所述行为有关的事由而被解雇或自行辞职的被申请人或其任何关联方的雇员或前雇员； (d) 截至索赔截止日，已因与命令所述行为或美国证券交易委员会任何相关行动有关的事项受到刑事指控的任何人； (e) 被申请人拥有或曾经拥有控制性权益的商号、信托、公司、高级管理人员或其他实体； (f) 基金管理人、其雇员，以及协助基金管理人履行基金管理人职责的人员；或 (g) 有偿购买或受让他人从公平基金获得赔偿之权利的人；但本项规定不得解释为排除因赠与、继承或遗嘱遗赠而取得该项权利的人。

The undersigned represents and certifies UNDER PENALTY OF PERJURY that: 1. I am NOT: (a) a Respondent; (b) a present or former officer or director of the Respondents or an assign, creditor, heir, distributee, spouse, parent, dependent child or controlled entity of any of the foregoing persons or entities; (c) an employee or former employee of the Respondents or any of its affiliates who has been terminated for cause or has otherwise resigned, in connection with the conduct described in the Order; (d) a Person who, as of the Claims Bar Date, has been the subject of criminal charges related to the conduct described in the Order or any related Commission action; (e) a firm, trust, corporation, officer, or other entity in which Respondents have or had a controlling interest; (f) the Fund Administrator, its employees, and those persons assisting the Fund Administrator in its role as the Fund Administrator; or (g) a purchaser or assignee of another Person’s right to obtain a recovery from the Fair Fund for value; provided, however, that this provision shall not be construed to exclude those Persons who obtained such a right by gift, inheritance or devise.

2. 本人理解，基金管理人为核实本人的索赔或支付索赔款，可能要求本人提供补充信息；本人同意提供基金管理人为上述目的而要求的任何信息； 3. 本人同意，如基金管理人依照分配方案进行分配，则在任何情况下，基金管理人或其代理人均不因此对本人或任何其他人承担责任； 4. 本人同意，本人一旦收到并接受GTV传媒集团公平基金的分配款，即视为已放弃本人可能对基金管理人及其代理人享有的一切请求权，且视为已被禁止就任何此类请求权提起诉讼或提出主张； 5. 如本人是代表集合投资基金或实体中的多名索赔人进行投资并担任其代表的托管人、受托人或专业人士，本人另行证明，收到的任何分配款均将仅为现有或原有集合投资者的利益而分配； 6. 如本人代表公司、合伙企业或其他商业实体签署本索赔表，本人具有代表该实体行事并签署本索赔表的合法权限； 7. 本人同意就与本项索赔有关的一切事项接受美国证券交易委员会的管辖； 8. 本人已阅读上述由本人提交的索赔表，包括所有附件及随附材料，并证明该索赔表连同所有附件及随附材料在各方面均真实、准确、完整；本人亦证明本表及其附件所载全部信息，包括交易详情，均准确、完整；以及 9. 本人未授权任何其他人就本索赔表所列相同损失和／或交易代表本人提交索赔表，亦不知悉任何其他人曾如此提交。

2. I understand that the Fund Administrator may require additional information from me in order to validate or pay my claim, and I agree to provide any information requested by the Fund Administrator for those purposes; 3. I agree that under no circumstances shall the Fund Administrator or its agents incur any liability to me or to any other Person if it makes a distribution in accordance with the Distribution Plan; 4. I agree that upon receipt and acceptance by me of a distribution from the GTV Media Group Fair Fund, I shall be deemed to have released all claims that I may have against the Fund Administrator and its agents and shall be deemed enjoined from prosecuting or asserting any such claims; 5. If I am a custodian, trustee, or professional investing on behalf of and representing more than one claimant in a pooled investment fund or entity, I also attest that any distribution received will be allocated solely for the benefit of current or former pooled investors; 6. If signing this Claim Form on behalf of a corporation, partnership or other business entity, I have the legal authority to act on its behalf and execute this Claim Form; 7. I agree to submit to the jurisdiction of the Securities and Exchange Commission for all purposes relating to this claim; 8. I have read my foregoing Claim Form, including any attachments and enclosures, and certify that the Claim Form including any attachments and enclosures is true, correct, and complete, in every aspect; and am attesting to the accuracy and completeness of all the information contained herein and attached hereto, including transactional details; and 9. I have not authorized nor am aware of anyone else who has filed a Claim Form on my behalf for the same losses and/or transactions included in this Claim Form.

8 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

8 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

本人（我们）证明，本人（我们）在本索赔证明表中提供的全部信息均真实、准确、完整，且随表提交的文件（如有）均为其所称文件的真实、完整、准确副本；如有虚假，愿承担伪证责任。

UNDER THE PENALTIES OF PERJURY, I (WE) CERTIFY THAT ALL OF THE INFORMATION WITHIN THE PROOF OF CLAIM FORM PROVIDED BY ME (US) ON THIS FORM IS TRUE, CORRECT, AND COMPLETE, AND THAT THE DOCUMENTS, IF ANY, SUBMITTED HEREWITH, ARE TRUE, COMPLETE, AND CORRECT COPIES OF WHAT THEY PURPORT TO BE.

签署日期：________________（月／年）_________日 签署地点：__________________________________（城市／州／国家）

Executed this _________ day of ________________ in __________________________________ (Month/Year) (City/State/Country)

______________________________________｜_________________________________ （在此签名）｜（在此签名）

______________________________________ _________________________________ (Sign your name here) (Sign your name here)

______________________________________｜_________________________________ （在此打印或以正楷填写姓名）｜（在此打印或以正楷填写姓名）

______________________________________ _________________________________ (Type or Print your name here) (Type or Print your name here)

______________________________________｜_________________________________ 如非以个人身份签署，请注明签署人身份，例如遗嘱执行人、总裁、受托人、托管人等。｜如非以个人身份签署，请注明签署人身份，例如遗嘱执行人、总裁、受托人、托管人等。

______________________________________ _________________________________ Capacity of person signing, if other than an individual, Capacity of person signing, if other than an individual, e.g., executor, president, trustee, custodian, etc. e.g., executor, president, trustee, custodian, etc.

9 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

9 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy

1. 请签署索赔表。

1. Please sign the Claim Form.

如本索赔表代表共同索赔人提交，则双方均须签署索赔表。

If this Claim Form is being made on behalf of joint claimants, then both must sign the Claim Form.

2. 请记住，仅附上符合要求的证明文件副本，因为这些文件不会退还给您。

2. Remember to attach only copies of acceptable supporting documentation as these documents will not be returned to you.

3. 请勿在索赔表或任何证明文件的任何部分使用荧光笔。

3. Please do not highlight any portion of the Claim Form or any supporting documents.

4. 请留存填写完整的索赔表及证明文件副本，供您自行备查。

4. Keep copies of the completed Claim Form and documentation for your own records.

5. 基金管理人将在收到您的索赔表后60日内，以电子邮件确认收件。

5. The Fund Administrator will acknowledge receipt of your Claim Form by email, within 60 days of receipt.

您只有收到确认电子邮件，才能确认索赔已经提交。

Your claim is not confirmed as submitted until you receive an acknowledgement email.

如您在60日内未收到确认电子邮件，请拨打免费电话866-853-5013联系基金管理人。

IF YOU DO NOT RECEIVE AN ACKNOWLEDGEMENT EMAIL WITHIN 60 DAYS, PLEASE CALL THE FUND ADMINISTRATOR TOLL FREE AT 866-853-5013.

6. 如您今后变更地址，或本索赔表被寄至旧地址或错误地址，请及时通过电子邮件[email protected]，或致函下列地址，向基金管理人书面通知您的新地址。

6. If your address changes in the future, or if this Claim Form was sent to an old or incorrect address, please promptly send the Fund Administrator written notification of your new address by email at [email protected] or mail to the Fund Administrator to the address below.

如您更改姓名，请通知基金管理人。

If you change your name, please inform the Fund Administrator.

7. 如对您的索赔有任何疑问或关切，请致函下列地址联系基金管理人，拨打免费电话866-853-5013，发送电子邮件至[email protected]，或访问www.GTVMediaGroupFairFund.com。

7. If you have any questions or concerns regarding your claim, please contact the Fund Administrator in writing at the below address, toll- free at 866-853-5013, by email at [email protected], or visit www.GTVMediaGroupFairFund.com.

请勿就您的索赔问题致电美国证券交易委员会或被申请人。

Please DO NOT call the SEC or the Respondents with questions regarding your claim.

本索赔表必须提交给基金管理人：在线提交的，须最迟于索赔截止日太平洋标准时间（PST）晚上11:59送达；邮寄的，邮戳日期不得晚于索赔截止日；采用任何其他方式提交的，须在规定期限内送达基金管理人的下列地址：

THIS CLAIM FORM MUST BE SUBMITTED TO THE FUND ADMINISTRATOR SO THAT IT IS RECEIVED ONLINE NO LATER THAN 11:59 P.M. PST ON THE CLAIMS BAR DATE; IF SENT BY MAIL, POSTMARKED NO LATER THAN THE CLAIMS BAR DATE; OR IF SENT BY ANY OTHER METHOD, RECEIVED BY THE FUND ADMINISTRATOR AT THE FOLLOWING ADDRESS NO LATER THAN:

GTV传媒集团公平基金 由JND Legal Administration转交 91403号邮政信箱 华盛顿州西雅图市，邮政编码98111

GTV Media Group Fair Fund c/o JND Legal Administration P.O. Box 91403 Seattle, WA 98111

请知悉，全面处理所有已提交的索赔表需要相当长的时间。

You should be aware that it will take a significant amount of time to fully process all the submitted Claim Forms.

有关工作将在时间允许的情况下尽快完成。

This work will be completed as promptly as time permits.

请耐心等候；如地址变更，请通过电子邮件[email protected]，或致函紧接上方所列地址，通知基金管理人。

Please be patient and notify the Fund Administrator of any change of address by email at [email protected] or mail to the Fund Administrator to the address listed directly above.

10 如有疑问，请访问www.GTVMediaGroupFairFund.com或拨打免费电话866-853-5013。

10 Questions? Visit www.GTVMediaGroupFairFund.com or call toll-free 866-853-5013.

如需查阅JND的隐私政策，请访问https://www.jndla.com/privacy-policy

To view JND’s privacy policy, please visit https://www.jndla.com/privacy-policy