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Name(s) and Addresses of Registered Holder(s)
(Please fill-in) |
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Shares of Common
Stock Tendered* |
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Total
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*
Common Stock may only be tendered in increments of 20 shares, with each 20 shares of Common Stock being exchangeable in the Offer for one share of Series B1 Preferred Stock having a liquidation preference of $25.00 per share of Series B1 Preferred Stock
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X
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| | 2022 | |
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X
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| | 2022 | |
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X
Signature(s) of Holders
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Date
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| | 2022 | |
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Name of Firm:
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(Authorized signature)
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Address:
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Title:
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Name:
(Please type or print)
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(Zip Code)
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Date:
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