Notification of Works form - Composer/Author/Publisher - Samro

COMPOSER / AUTHOR / PUBLISHER WORK REGISTRATIONName and Surname (as per ID) / or Publisher NameIdentity Number / Company Registration NumberRegistration TypeCTBOUCATSUSBUILocalLocal & AgreeCatalogueLocal PurchaseForeign SaleContact Number(s)E-mail Address

I, THE UNDERSIGNED, DECLARE, ACKNOWLEDGE AND CONFIRM THE FOLLOWING:1. I AUTHORED/COMPOSED AND/OR PUBLISHED ALL WORKS MENTIONEDHEREUNDER.2. I HAVE, BY MEANS OF A SEPARATE DEED OF ASSIGNMENT, ASSIGNED TO SAMROMY PERFORMING, AND/OR MECHANICAL RIGHTS, AND/OR FILM SYNCHRONISATIONRIGHTS IN THE SAID WORK(S).3. I HEREBY ALSO LIST ALL AUTHORS/COMPOSERS AND/OR PUBLISHERS ELIGIBLETO REGISTER AS AUTHOR/COMPOSER AND/OR PUBLISHER.4. SAMRO SHALL NOT BE HELD LIABLE FOR ANY CLAIMS OF ANY KIND ARISING FROMDISPUTES AND ACTIONS RELATING TO MY INVOLVEMENT IN THE WORKSINDICATED HEREUNDER.DateSignatureComposer / AuthorPublisherThe person notifying is required to sendto SAMRO, together with this form, acopy of his/her Deed of Assignment andor Exclusive Song Writers Agreementswith the publisher only in cases where anagreement exist.Copies of contracts with film-producersshould also be sent to SAMRO.To obviate unnecessary duplication ofadministration, kindly keep a copy of allnotifications sent to SAMRO.FOR OFFICE USE ONLYBusiness Relations Nr:__________IPI Nr._______________________Received:____________________

1. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%2. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%3. TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%

4. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%5. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%6. TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%

7. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%8. Title Alternative TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%9. TitleDuration Instrumentation Type of Work Performing Artist(s) / GroupIV VS ISRights Holder Name(s) Capacity / Role Code PR% MR%

1. REGISTRATION TYPE:CTB: New registration sent by composer/author (Local Work)OU: New registration sent by publisher who signed a contract withcomposer/author (Local)CAT: Catalogue from abroad with list of rights which are supposed to beused in South Africa. Can also be works sub-published by the original(foreign) publisher to a South African sub-publisher.SU: A foreign publisher sells the rights for an individual song to a SouthAfrican publisher.SUBUI: A South African publisher sells the rights for an individual song to aforeign publisher (specific agreement works).2. TITLE OF WORK: The original / official title of the musical work.3. ALTERNATIVE TITLE(S): If the work has alternative title(s) or commonly usedtitle(s) please furnish these in the block.4. DURATION: The actual duration of the musical work in minutes and seconds.5. PERFORMING ARTIS(S)/GROUP: Please supply surname and name of performingartist in case where music was written for a specific artist or group.6. CAPACITY/ROLE CODE:A AuthorAD Adaptor (Text editor)AR Arranger (Music Editor)C ComposerCA Composer/AuthorE PublisherSA Sub-AuthorSE Sub-Publisher7. PR %: Performing Rights Share Percentage.8. MR%: Mechanical Rights Share Percentage.