Copyright Royalty BoardAttn: Licensing DivisionPO Box 70977Washington, DC 20024-0977O037cial BusinessPenalty for Private Use $300.00Forwarding and return postage guaranteed� 227 � address correction requested 037036036035034035033032 031030027035026025027027037036035034033032 031034030034033031 027026025024023035022021034 026020020035027033033026026030033032 027024033024025023025026024 037036 033034034037030026024� (036037022023 021033022024/033) American LegalNet, Inc. www.FormsWorkFlow.com How to File the Annual Statement of Account and Royalty FeeThe annual statement of account covers the entire accounting year, including the fourth quarter distribution, and provides for the reconciliation of the aggregated accounting of digital audio recording devices and media for the reported accounting year. (The reconciliation also provides for credits, underpayments, reductions, refunds, and royalties paid for quarters 12263.)036035034033032: � Make sure that you are using the right form and read the instructions in the form. Collect all the necessary information.033031030027026025: � Access 037ll-in statement of account form at http://www.copyright.gov/forms/formdart-a.pdf on a personal computer and print it out or hand print the information in dark ink. Give all the required information.032024035034025: � Sign in space H. The statement of account is not acceptable unless it bears the original handwritten signature of an o036cer, principal, or agent authorized to certify it pursuant to the Audio Home Recording Act of 1992 (Chapter 10, Section 1003(c)(2) of title 17 USC).036027023034032024: � Complete the report of the primary auditor in space I (see page iii of the instructions for more information).036035036032024: � Royalty fees must be paid by an electronic payment, pursuant to Section 201.28 (h)(1) of Title 37 , CFR. Make an electronic payment in the amount of the royalty fee due as calculated in space C. For detailed instructions, see circulars 74035 (on payments by wire), 74034 (on payments by Automated Clearing House credit), or 74033 (on payments using pay.gov), available at www.copyright.gov/circs/circ74 � n .033035022032024: � Send the completed statement of account to:Copyright Royalty Board Attn: Licensing Division PO Box 70977 Washington, DC 20024-0977033031021031026032024: Retain a copy of the entire statement, as 037led, in case it is needed for future reference.For Copyright O036ce regulations, forms, or additional information, visit www.copyright.gov or contact the Licensing Division between 8:30 035032 and 5:00 031032 eastern: (202) 707-8150 (phone); (202) 707-0905 (fax); or licensing@copyright.gov (email). American LegalNet, Inc. www.FormsWorkFlow.com 036035032035026020 021025033021032035026025: � The statement of account must be 017led within two months after the close of the fourth quarter covered by the statement.Instructions are at the end of this form (pages i226iii).036037022 034037017016022035020r024 037036036035034025 030027025 037026032016Date received: � Amount: � Remittance number:030026035024025021 027024033024025027 034037017016022035020r024 037036036035034025Annual Statement of Account for Digital Audio Recording Products5 � A � 033034034037030026024035026020 017025022035037021 034037f025022025021 031016 024r035027 033026026030033032 027024033024025023025026024 037036 033034034037030026024 � 1 � Check the applicable box. If your accounting period is the calendar year, enter the year; if it is a 037scal year, enter the 12-month period and years. � Calendar year: � January 1 through December 31, 20 � / � Fiscal year: � beginning � � / , 20 � / � and ending � / � / , 20 � / � 2 � Enter the three-month period and year(s) for the fourth quarter of this 037ling.Quarter 4 beginning � � / , 20 � / � and ending � / � / , 20 � / � B � 026033023025, 033021021022025027027, 033026021 036035032035026020 027024033024030027Give the full legal name of the 223manufacturing or importing party224 and any other name used for the purpose of conducting the business of manufacturing and distributing or importing and distributing digital audio recording products. � 1 � Legal name � � 2 � Mailing address � � � Give other business name(s), if di030erent from Line 1. � 3 � Business name � � � 4 � Check the applicable box to identify your 037ling status. � Manufacturer � � Importer � � Manufacturer and importerPrivacy Act Notice: Chapter 10 of title 17, United States Code, authorizes the Copyright O037ce to collect the personally identifying information (PII) requested on this form in order to process your statement of account. PII is any personal information that can be used to identify or contact an individual, such as names, addresses, and telephone numbers. The Copyright O037ce collects this PII in order to identify the entities making the royalty fee payments. By providing your PII, you are agreeing to this routine use of it. The e036ects of not providing the PII requested are that it may delay processing of your statement of account, and it may a036ect the legal su037ciency of the 035ling, a determination that would be made by a court of law. � Check here if this is the manufacturer's/importer's 037rst 037ling. If not, enter the ID number assigned by the Licensing Division � / 037036035034 033032035031 � 030 � 032Return to:Copyright Royalty Board Attn: Licensing Division PO Box 70977 Washington, DC 20024-0977027036026037025033024026031025032023 American LegalNet, Inc. www.FormsWorkFlow.com 025013033023017032025 Do not include the royalty fee from this example in your computations. � C � computation of royalty fee026027032031: � If you need more space, photocopy space C and attach the additional page(s) to the statement of account.035026 020031026031034017016: � The information you list in space C incorporates your distribution of devices and media during the entire accounting year. Columns 12267 and lines 12268 permit you to reconcile your accounting of activities for the year to what was actually distributed or adjusted based on your company222s accounting records. See page ii of the instructions for more information about completing this space.030027rf023032017032035027026 027036 034027013017016032013 036031031: � The formula to compute the royalty fee involves 14 components combined on pages 22263. There are two di030erent formulas for computing the royalty fee: � (1) a formula for audio recording devices that are identi-037ed by the letters A, B, C, or D in column 4; and (2) a formula for audio recording media that are identi037ed by the letter E in column 4. For further explanation of the information required for each column, see pages ii226iii of the instructions.030027rf023032035026020 032024031 034027013017016032013 036031031 036027034 025035020035032017016 017023025035027 034031030027034025035026020 025031021035030031033: � On a line-by-line basis, enter the information in columns 12268, 10, and 12 and compute the royalty fee:Step 1: � Multiply column 7 by column 8 and enter the result in column 9.Step 2: � Multiply column 7 by column 12 and enter the result in column 13.Step 3: � Multiply column 6 037rst by column 7, then by column 10, and enter the result in column 11.Step 4: � Select the appropriate royalty fee from column 9, 11, or, 13 as explained in the instructions, page ii, and enter that 037gure in column 14.030027rf023032035026020 032024031 034027013017016032013 036031031 036027034 025035020035032017016 017023025035027 034031030027034025035026020 r031025035017: � On a line-by-line basis, enter the information in columns 12267 and 10 and compute the royalty fee:Step 1: � Multiply column 6 037rst by column 7, then by column 10.Step 2: � Enter the result of step 1 in column 14.030027rf023032035026020 032024031 032027032017016 034027013017016032013 036031031: Complete lines 12268 on page 3.034027023026025035026020 027036036 025027016016017034033: You may not round o030 cents to whole dollars when calculating the royalty fee on a line-by-line basis in space C. However, you may round cents to whole dollars for the total fee due on line 8, space C. � � � � � � � � � � � � 2 � 267 � 027026025032 024035025023022035 � 027036