| |
If delivering by hand, express mail, courier,or other expedited service:
|
| |
By mail:
|
|
| |
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
| |
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
|
| | |
DESCRIPTION OF SHARES TENDERED
|
| | ||||||||||||||||
| | |
Name(s) and Address(es)
of Registered Owner(s) (If blank, please fill in exactly as name(s) appear(s) on share certificate(s)) |
| | |
Shares Tendered
(attached additional list if necessary) |
| | ||||||||||||
| | | | | | |
Certificated Shares**
|
| | | | | | ||||||||
| |
Certificate Number(s)*
|
| | |
Total Number of
Shares Represented by Certificate(s)* |
| | |
Number of Shares
Surrendered** |
| | |
Book Entry Shares
Surrendered |
| | |||||
| | | | | | | | | | | | | | | | | |||||
| | | | | | | | | | | | | | | | | |||||
| | | | | | | | | | | | | | | | | |||||
| | Total Shares | | | | | | | | | | | | | | | |||||
| | |
*
Need not be completed by book-entry stockholders.
**
Unless otherwise indicated, it will be assumed that all shares of common stock represented by certificates described above are being tendered hereby. See Instruction 4.
|
| | ||||||||||||||||
| |
SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 4, 5 and 7) |
|
| | 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:
|
|
| |
Name:
(Please Print)
|
|
| | Address: | |
| |
Address:
(Include Zip Code)
|
|
| |
(Tax Identification or Social Security Number)
|
|
| |
☐
Credit Shares tendered by book-entry transfer that are not accepted for payment to the DTC account set forth below.
(DTC Account Number)
|
|
| |
SPECIAL DELIVERY INSTRUCTIONS
(See Instructions 1, 4, 5 and 7) |
|
| | 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:
|
|
| |
Name:
(Please Print)
|
|
| | Address: | |
| |
Address:
(Include Zip Code)
|
|
| |
Name(s):
(Please Print)
|
|
| | Capacity (full title): | |
| | Address: | |
| |
Address:
(Include Zip Code)
|
|
| | Area Code and Telephone Number: | |
| |
Tax Identification or
Social Security No.:
|
|
| | Name of firm: | |
| |
Name of firm:
(Include Zip Code)
|
|
| | Authorized Signature: | |
| | Name: | |
| |
Name:
(Please Type or Print)
|
|
| | Area Code and Telephone Number: | |
| |
If delivering by hand, express mail, courier,or other expedited service:
|
| |
By mail:
|
|
| |
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
| |
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
|