I, iaca testu (Performer's Full Legal Name), understand that all the information required

by this document is required to comply with United States federal law and any false statement or misrepresentation is a crime under the

United States law.

Birth Date: 06 06 1979

Age: 37

I have also used the following names, stage names, aliases, nicknames and married and /or maiden names:

(1) (2)

(3) (4)

If more than 4 please attach a separate sheet, signed by the performer, with all names.

X Check this box to attest you have read and agree with the Terms of Use of Cam4 and you

acknowledge you have licensed your images to Cam4 and that you will keep all documents and information required

to be kept by 18 U.S.C. §2257 and 18 U.S.C. §2257A and associated regulations, 28 CFR 75 et seq., in the manner required by law,

in recognition that you are the "producer" of said images.

PERFORMER'S SWORN STATEMENT:

I, iaca testu (full legal name) pursuant to 28 U.S.C. $1746 and the penalties of

perjury, under the laws of the United States, swear that the above is true and correct and that the ID

which I have provided, a copy of which is attached and signed by me, was lawfully obtained by me

and has not been forged or altered.

Today's Date: 2016-06-09

I agree iaca testu

Performer's Full Legal Name