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By First Class Mail:
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By Registered, Certified
or Express Mail or Overnight Courier: |
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Computershare Shareholder Services, Inc.
Attn: Voluntary Corporate Actions P.O. Box 43011 Providence, RI 02940-3011 |
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Computershare Shareholder Services, Inc.
Attn: Voluntary Corporate Actions 150 Royall Street Suite V Canton, MA 02021 |
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DESCRIPTION OF SHARES TENDERED
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Name(s) and Addresses of Registered Holder(s): (Please Fill in, if Blank, Exactly as Name(s) Appear(s) on Certificate(s))
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Shares Tendered ***
(Attach Additional Signed Schedule if necessary) |
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Certificate
Number(s)* |
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Total
Number of Shares Evidenced by Certificates** |
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Number
of Shares Tendered |
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Dividend
Reinvestment Shares Tendered |
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Total Shares
Tendered |
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Account Number:
Transaction Code Number:
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SPECIAL PAYMENT INSTRUCTIONS
(See Instruction 8) |
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| | To be completed ONLY if certificates for Shares not tendered or not purchased are to be issued in the name of and sent to someone other than the undersigned. | | |
| | Issue Certificate to: | | |
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Name:
(Please Print)
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Address:
(City, State, Zip Code)
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(Complete Substitute Form W-9)
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(Tax Identification (Social Security) Number)
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SPECIAL DELIVERY INSTRUCTIONS
(See Instruction 8) |
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| | To be completed ONLY if certificates for Shares not tendered or not purchased are to be issued in the name of the undersigned, but sent to someone other than the undersigned or to the undersigned at an address other than that shown above. | | |
| | Mail Certificate to: | | |
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Name:
(Please Print)
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Address:
(City, State, Zip Code)
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SIGN HERE
(IMPORTANT: COMPLETE AND SIGN THE SUBSTITUTE FORM W-9 HEREIN)
(Signature(s) of Stockholder(s))
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Dated:
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| | (Must be signed by the registered holder(s) exactly as name(s) appear(s) on certificate(s) for the Shares or on a security position listing or by person(s) authorized to become registered holder(s) by certificate(s) and documents transmitted herewith. If signature is by attorney-in-fact, executor, administrator, trustee, guardian, agent, officer of a corporation or another person acting in a fiduciary or representative capacity, please provide the following information. See Instruction 5.) | | |
| | (Must be signed by the registered holder(s) exactly as name(s) appear(s) on certificate(s) for the Shares or on a security position listing or by person(s) authorized to become registered holder(s) by certificate(s) and documents transmitted herewith. If signature is by attorney-in-fact, executor, administrator, trustee, guardian, agent, officer of a corporation or another person acting in a fiduciary or representative capacity, please provide the following information. See Instruction 6.) | | |
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Name(s)
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(Please Print)
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Capacity (Full Title)
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Address
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CityStateZip Code
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Area Code and Telephone Number
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Employer Identification or
Social Security Number
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GUARANTEE OF SIGNATURE(S)
(See Instructions 1 and 6) |
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Authorized Signature(s)
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Name:
(Please Print)
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Name of Firm
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Address
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City State Zip Code
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| | Dated: | | |
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By First Class Mail:
|
| |
By Registered, Certified
or Express Mail or Overnight Courier: |
|
|
Computershare Shareholder Services, Inc.
Attn: Voluntary Corporate Actions P.O. Box 43011 Providence, RI 02940-3011 |
| |
Computershare Shareholder Services, Inc.
Attn: Voluntary Corporate Actions Suite V 150 Royall Street Canton, MA 02021 |
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