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THE TERMINATION DATE AND THE WITHDRAWAL DEADLINE IS 5:00 P.M., NEW YORK
CITY TIME, ON AUGUST 2, 2024, UNLESS EXTENDED (THE “TERMINATION DATE”) |
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If delivering by hand, express mail, courier,
or other expedited service:
Equiniti Trust Company, LLC
55 Challenger Road Suite # 200 Ridgefield Park, New Jersey 07660 Attn: Reorganization Department |
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By mail:
Equiniti Trust Company, LLC
Operations Center Attn: Reorganization Department P.O. Box 525 Ridgefield Park, New Jersey 07660 |
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DESCRIPTION OF SHARES OF COMMON STOCK TENDERED
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Names(s) and Address(es) of Registered Holder(s)
(Please Fill in, if blank) |
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Share Certificate(s) and Shares(s) Tendered
(Please attach additional signed list, if necessary) |
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Common Stock
Share Certificate Number(s)(1) |
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Total Number of
Shares of Common Stock Represented by Share Certificate(s)(1) |
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Number of Shares
of Common Stock Tendered(2) |
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Total Shares Tendered
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(1)
Need not be completed by shareholders who deliver Shares by book-entry transfer (“Book-Entry Shareholders”).
(2)
Unless otherwise indicated, all Shares represented by Share Certificates delivered to the Depositary will be deemed to have been tendered. See Instruction 4.
☐
Check here if Share Certificates have been lost or mutilated.
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| | [ ] | | | CHECK HERE IF TENDERED SHARES ARE BEING DELIVERED BY BOOK-ENTRY TRANSFER TO THE ACCOUNT MAINTAINED BY THE DEPOSITARY WITH DTC AND COMPLETE THE FOLLOWING (ONLY FINANCIAL INSTITUTIONS THAT ARE PARTICIPANTS IN DTC MAY DELIVER SHARES BY BOOK-ENTRY TRANSFER): | |
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Name of Tendering Institution:
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DTC Participant Number:
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Transaction Code Number:
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| | Issue: ☐ Check and/or ☐ Share Certificates to: | | ||||||
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Credit Shares tendered by book-entry transfer that are not accepted for payment to the DTC account set forth below.
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| | Deliver: ☐ Check(s) and/or ☐ Share Certificates to: | | ||||||
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SUBSTITUTE
FORM W-9
Department of the Treasury
Internal Revenue Service |
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Part 1 — PLEASE PROVIDE YOUR TIN IN THE BOX AT RIGHT AND CERTIFY BY SIGNING AND DATING BELOW
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Social Security Number
OR
Employer Identification Number
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Part 2 — Check appropriate box for federal tax classification; check only one:
☐ Individual/Sole Proprietor ☐ C Corporation ☐ S Corporation
☐ Partnership ☐ Trust/estate ☐ Limited Liability Company:
☐ Other (please specify)
☐ Check this box if you checked Partnership, Trust/estate or LLC and these are any foreign partners, owners or beneficiaries
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For Limited Liability Companies, please enter the appropriate tax classification on the line provided next to the phrase “Limited Liability Company”:
C = C Corporation
S = S Corporation
P =Partnership
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Part 3 — FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING, ENTER CODE, IF ANY, FOR PAYEES EXEMPT FROM FATCA Reporting Enter Code, IF ANY
(See page 2 of enclosed guideline and W-9 instructions at www.irs.gov/FormW9)
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Payer’s Request for Taxpayer Identification
Number (TIN) and Certification |
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Part 4 — Certification Under Penalties of Perjury, I certify that:
(1)
The number shown on this form is my current taxpayer identification number (or I am waiting for a number to be issued to me),
(2)
I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (the “IRS”) that I am subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding and
(3)
I am a U.S. person (including a U.S. resident alien).
(4)
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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Part 5
☐ Check box
if Awaiting TIN
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Certification instructions — You must cross out item (2) in Part 4 above if you have been notified by the IRS that you are subject to backup withholding because of underreporting interest or dividends on your tax return. However, if after being notified by the IRS that you are subject to backup withholding you receive another notification from the IRS stating that you are no longer subject to backup withholding, do not cross out item (2).
SIGNATURE
DATE
NAME
ADDRESS
CITY
STATE
ZIP CODE
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PAYER’S NAME: Equiniti Trust Company, LLC
CERTIFICATE OF AWAITING TAXPAYER IDENTIFICATION NUMBER |
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I certify, under penalties of perjury, that a taxpayer identification number has not been issued to me, and either (a) I have mailed or delivered an application to receive a taxpayer identification number to the appropriate Internal Revenue Service Center or Social Security Administration Office or (b) I intend to mail or deliver an application in the near future. I understand that if I do not provide a taxpayer identification number before payment is made, a portion of such reportable payment will be withheld.
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Signature
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Date
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