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THE OFFER AND WITHDRAWAL RIGHTS WILL EXPIRE AT 12:01 A.M., NEW YORK CITY TIME, ON WEDNESDAY, SEPTEMBER 27, 2017, UNLESS THE OFFER IS EXTENDED (SUCH DATE AND TIME, AS IT MAY BE EXTENDED, THE “EXPIRATION DATE”) OR EARLIER TERMINATED.
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If delivering by mail:
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If delivering by hand or courier:
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American Stock Transfer & Trust Company, LLC
Operations Center Attn: Reorganization Department P.O. Box 2042 New York, NY 10272-2042 |
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American Stock Transfer & Trust Company, LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue New York, NY 11219 |
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Name(s) and Address of Registered Holder(s)
If there is any error in the name or address shown below, please make the necessary corrections |
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| | | DESCRIPTION OF SHARES SURRENDERED (Please fill in. Attach separate schedule if needed) |
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Certificate No(s)
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Number of Shares
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| | | TOTAL SHARES ☞ | | | | | | |
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 4, 5, 6 and 7) |
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| | | To be completed ONLY if Share Certificate(s) not tendered or not accepted for payment and/or the check for the purchase price in consideration of Shares accepted for payment are to be issued in the name of someone other than the undersigned or if Shares tendered by book-entry transfer which are not accepted for payment are to be returned by credit to an account maintained at DTC other than that designated above. | | |
| | | Issue: ☐ Check and/or ☐ Share Certificates to: | | |
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Name:
(Please Print)
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Address:
(Include Zip Code)
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(Tax Identification or Social Security Number)
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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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(DTC Account Number)
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SPECIAL DELIVERY INSTRUCTIONS
(See Instructions 1, 4, 5, 6 and 7) |
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| | | To be completed ONLY if Share Certificate(s) not tendered or not accepted for payment and/or the check for the purchase price of Shares accepted for payment are to be sent to someone other than the undersigned or to the undersigned at an address other than that shown in the box titled “Description of Shares Tendered” above. | | |
| | | Deliver: ☐ Check(s) and/or ☐ Share Certificates to: | | |
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Name:
(Please Print)
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Address:
(Include Zip Code)
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IMPORTANT — SIGN HERE
(U.S. Holders Please Also Complete the Enclosed IRS Form W-9) (Non-U.S. Holders Please Obtain and Complete IRS Form W-8BEN or Other Applicable IRS Form W-8) |
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(Signature(s) of Stockholder(s))
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Dated: , 2017
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| | | (Must be signed by registered owner(s) exactly as name(s) appear(s) on Share Certificate(s) or on a security position listing or by person(s) authorized to become registered owner(s) by certificates and documents transmitted herewith. If signature is by trustees, executors, administrators, guardians, attorneys-in-fact, officers of corporations or others acting in a fiduciary or representative capacity, please set forth full title and see Instruction 5. For information concerning signature guarantees, see Instruction 1.) | | |
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Name(s):
(Please Print)
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| | | Capacity (full title): | | |
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Address:
( Include Zip Code)
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| | | Area Code and Telephone Number: | | |
| | | Tax Identification or Social Security No.: | | |
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GUARANTEE OF SIGNATURE(S)
(For use by Eligible Institutions only; see Instructions 1 and 5) |
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Name of Firm:
(Include Zip Code)
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| | | Authorized Signature: | | |
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Name:
(Please Type or Print)
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| | | Area Code and Telephone Number: | | |
| | | Dated: , 2017 | | |
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Place medallion guarantee in space below:
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SUBSTITUTE FORM
W-9
Department of the Treasury Internal Revenue Service
Payer’s Request for Taxpayer Identification
Number (TIN) and Certification |
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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 — FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING (See Page 2 of enclosed Guidelines) |
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Part 3 — 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 4 —
Awaiting TIN ☐ |
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Certification instructions — You must cross out item (2) in Part 3 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: American Stock Transfer & Trust Company, LLC
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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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For this type of account:
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1.
An individual’s account
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| | The individual | |
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2.
Two or more individuals (joint account)
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| | The actual owner of the account or, if combined funds, the first individual on the account(1) | |
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3.
Husband and wife (joint account)
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| | The actual owner of the account or, if joint funds, the first individual on the account(1) | |
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4.
Custodian account of a minor (Uniform Gift to Minors Act)
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| | The minor(2) | |
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5.
Adult and minor (joint account)
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| | The adult or, if the minor is the only contributor, the minor(1) | |
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6.
Account in the name of guardian or committee for a designated ward, minor, or incompetent person
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| | The ward, minor, or incompetent person(3) | |
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7.a.
The usual revocable savings trust account (grantor is also trustee)
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| | The grantor-trustee(1) | |
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b.
So-called trust account that is not a legal or valid trust under state law
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| | The actual owner(1) | |
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For this type of account:
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| | Give the EMPLOYER IDENTIFICATION number of — |
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8.
Sole proprietorship account
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| | The owner(4) | |
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9.
A valid trust, estate or pension trust
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| | The legal entity(5) | |
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10.
Corporate account
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| | The corporation | |
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11.
Religious, charitable, or educational organization account
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| | The organization | |
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12.
Partnership account held in the name of the business
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| | The partnership | |
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13.
Association, club, or other tax-exempt organization
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| | The organization | |
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14.
A broker or registered nominee
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| | The broker or nominee | |
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15.
Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments
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| | The public entity | |
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If delivering by mail:
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If delivering by hand or courier:
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American Stock Transfer & Trust Company, LLC
Operations Center Attn: Reorganization Department P.O. Box 2042 New York, New York 10272-2042 |
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American Stock Transfer & Trust Company, LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
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