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DESCRIPTION OF SHARES TENDERED
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(Must be signed by all registered stockholders; include legal
capacity if signing on behalf of an entity) (Please fill in name and address, if blank) |
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Shares Certificate(s) and Share(s) Tendered
(Attach additional signed list, if necessary) |
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Certificate
Number(s) and/or indicate Book-Entry Shares |
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Total Number of
Shares Represented by Share Certificate(s) |
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Total Number of
Shares Tendered(1)(2) |
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| | | | | | | Total Shares Tendered | | | | | | | | | | |
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 5 and 6) |
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| | | To be completed ONLY if the (check or shares) accepted for payment is/are to be issued in the name of someone other than the undersigned. | | |
| | | Issue To: | | |
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Name
(Please Print)
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Address
(Include Zip Code)
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(Recipient must complete Substitute Form W-9 below)
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SPECIAL DELIVERY INSTRUCTIONS
(See Instructions 1, 5 and 6) |
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| | | To be completed ONLY if the (check or shares) (is/are) to be sent to someone other than the undersigned or to the undersigned at an address other than that shown under “Description of Shares Tendered.” | | |
| | | Mail To: | | |
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Name
(Please Print)
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Address
(Include Zip Code)
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Signature of Owner
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Signature of Owner
(Signature(s) of Owner(s))
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Name(s) (please print)
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Capacity (Full Title)
(See Instructions)
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Address
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Phone number:
(Include Zip Code)
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If delivering by mail:
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If delivering by courier:
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Computershare Trust Company, N.A.
c/o Voluntary Corporate Actions P.O. Box 43011 Providence, Rhode Island 02940-3011 |
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Computershare Trust Company, N.A.
c/o Voluntary Corporate Actions 250 Royall Street, Suite V Canton, MA 02021 |
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