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By Mail:
Equiniti Trust Company, LLC Operations Center Attn: Reorganization Department P.O. Box 49 Newark, New Jersey 07101 |
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By hand, express mail, courier, or other expedited service:
Equiniti Trust Company, LLC 55 Challenger Road Suite # 200 Ridgefield Park, New Jersey 07660 Attn: Reorganization Department |
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DESCRIPTION OF SHARES TENDERED
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Name(s) and Address(es) of Registered Holder(s) (Please fill in, if blank, exactly as name(s) appear(s) in book-entry form. If there is any error in the name or address shown below, please make the necessary corrections) (Attach additional signed list if necessary)
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Total Number of Shares Tendered*
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Total Shares
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*
Unless otherwise indicated, it will be assumed that all Shares described in the chart above are being tendered. See Instruction 4.
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Name of Tendering Institution:
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DTC Account Number
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| | Transaction Code Number | | |
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Name(s) of Tendering Stockholder(s):
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Window Ticket Number (if any):
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Date of Execution of Notice of Guaranteed Delivery:
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Name of Eligible Institution that Guaranteed Delivery:
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 5, 6 and 7) |
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| | To be completed ONLY if the check for the purchase price of Shares accepted for payment is to be issued in the name of someone other than the undersigned. | | |
| | Issue check to: | | |
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Name:
(Please Print)
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Address:
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(Include Zip Code)
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(Taxpayer Identification No. (e.g., Social Security No.)) (Also Complete, as appropriate, IRS Form W-9 Included Below)
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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 Shares accepted for payment is to be mailed to someone other than the undersigned or to the undersigned at an address other than that shown above. | | |
| | Mail check to: | | |
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Name:
(Please Print)
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Address:
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(Include Zip Code)
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(Signature(s) of Holder(s) of Shares)
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| Dated: | |
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Name(s):
(Please Print)
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Capacity (full title) (See Instruction 5):
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Address:
(Include Zip Code)
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Area Code and Telephone No.:
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Tax Identification No. (e.g., Social Security No.) (See IRS Form W-9 included below):
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CERTIFICATE OF TAXPAYER AWAITING IDENTIFICATION NUMBER
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| | I certify under the 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 to the Depositary or otherwise establish an exemption from backup withholding, 24% of all reportable payments made to me will be withheld, but will be refunded to me if I provide a certified taxpayer identification number within 60 days. | | | |||||||||
| | Signature: | | |
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| | Date: | | |
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By Mail:
Equiniti Trust Company, LLC Operations Center Attn: Reorganization Department P.O. Box 49 Newark, New Jersey 07660 |
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By hand, express mail, courier, or other expedited service:
Equiniti Trust Company, LLC 55 Challenger Road Suite # 200 Ridgefield Park, New Jersey 07660 Attn: Reorganization Department |
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