PERFORMER RECORD-KEEPING COMPLIANCE FORM

PURSUANT TO 18 U.S.C. § 2257

PERFORMER IDENTIFYING INFORMATION: Performer understands that all the information
given in this Record-Keeping Compliance Form is being provided to comply with federal law and any
false statement will subject Performer to both civil action by Producer as well as possible criminal
prosecution under federal and state laws.
GUTIERREZ RAMIREZ
(a)__________________________________________________________________________________
Legal Family/Last/Surname(s)
ROGER JOSE
___________________________________________________________________________________
Legal Given/First/Middle Name(s)
11/01/1997
(b)__________________________________________________________________________________
Date of Birth

(c) Primary identification document of Performer must be government issued photo ID such as
passport, driver’s license, motor vehicle department ID, or military ID (each should be described,
including the ID number):

Identification Card
Form of Identification:_________________________________________________________________

Republic of Venezuela
Issuing Authority:_____________________________________________________________________

26363929
ID#:_________________________________________________________________________________

GUTIERREZ RAMIREZ ROGER JOSE

(d) ________________________________________ 08/30/2020
_______________________________________
Primary Producer Original Date of This Production

(e) All other names ever used (including previous legal names, stage names, Web handles, maiden or
married names, aliases, professional names and nicknames):

BUNTY
(1)________________________________________ (a)______________________________________
Stage Name for this Production All other names

(2)________________________________________ (b)_____________________________________
Maiden Name if Applicable All other names

(3)________________________________________ (c)______________________________________
Previous Legal name, if applicable All other names

SWORN STATEMENT: “UNDER 28 U.S.C. § 1746 AND THE PENALTIES OF PERJURY UNDER THE
LAWS OF THE UNITED STATES, I SWEAR THAT ALL INFORMATION I PROVIDED IN THIS
DOCUMENT IS TRUE AND CORRECT AND THAT EACH OF THE IDENTIFICATION DOCUMENTS
WHICH I HAVE PROVIDED ARE TRUE COPIES AND HAVE NOT BEEN FORGED OR ALTERED.”

__________________________________________ September 1, 2020

_______________________________________
Performer Signature Date