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If delivering by hand, express mail, courier,
or other expedited service:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
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By mail:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department P.O. BOX 2042 New York, NY 10272-2042 |
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DESCRIPTION OF SHARES TENDERED
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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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Shares Tendered
(attached additional list if necessary) |
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Certificate Shares**
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Book-Entry
Shares |
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Certificate
Numbers(s) |
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Total Number
of Shares Represented by Certificate(s) |
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Number
of Shares Represented by Certificate(s) Tendered*1 |
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Book-Entry
Shares Tendered |
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Total Shares
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| | | *1 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. | | | ||||||||||||||||||||
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DTC Account Number—
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Transaction Code Number—
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 5, 6 and 7) |
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SPECIAL DELIVERY INSTRUCTIONS
(See Instructions 1, 5, 6 and 7) |
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To be completed ONLY if the check for the purchase price of Company Shares accepted for payment and/or Share Certificates not tendered or not accepted for payment are to be issued in the name of someone other than the undersigned.
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| | To be completed ONLY if the check for the purchase price of Company Shares accepted for payment and/or Share Certificates not tendered or not accepted are to be mailed to someone other than the undersigned or to the undersigned at an address other than that shown above. | | |
| | | Issue ☐ Check and/or ☐ Shares Certificate to: | | | Mail ☐ Check and/or ☐ Shares Certificate to: | | |
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Name
(Please Print)
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Name
(Please Print)
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Address
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Address
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(Include Zip Code)
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(Include Zip Code)
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(Taxpayer Identification or Social Security No.)
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(Taxpayer Identification or Social Security No.)
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(Also Complete IRS Form W-9 Included Herein Or The Appropriate Version of IRS Form W-8, as applicable)
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(Also Complete IRS Form W-9 Included Herein Or The Appropriate Version of IRS Form W-8, as applicable)
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IMPORTANT
STOCKHOLDER: SIGN HERE |
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Signature(s) of Holder(s) of Company Shares
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Dated: , 2021
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Name(s)
(Please Print)
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Capacity (full title)
(See Instruction 5)
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(Include Zip Code)
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Address
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Area Code and
Telephone No.
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Tax Identification or Social Security No. (See IRS Form W-9 included herein)
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| | | Must be signed by registered holder(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 holder(s) by Share Certificates and documents transmitted herewith. If signature is by a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or other person 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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Guarantee of Signature(s)
(If Required — See Instructions 1 and 5) |
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Authorized Signature
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Name
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Name of Firm
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Address
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(Include Zip Code)
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Area Code and Telephone No.
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| | | Dated: , 2021 | | |
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(Additionally, please complete and return the IRS Form W-9 included in this Letter of Transmittal, or the appropriate version of IRS Form W-8, as applicable)
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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 (1) I have mailed or delivered an application to receive a taxpayer identification number to the appropriate IRS Center or Social Security Administration Office, or (2) I intend to mail or deliver an application in the near future. I understand that if I do not provide a taxpayer identification number by the time of payment, a portion of all reportable payments made to me will be withheld, but that such amounts will be refunded to me if I then provide a Taxpayer Identification Number within sixty (60) days. | | | |||
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Signature
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Date
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If delivering by mail:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
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If delivering by express mail, courier, or other expedited service:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department P.O. BOX 2042 New York, NY 10272-2042 |
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