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By Mail:
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By express mail, courier, or other expedited service:
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Computershare Trust Company, N.A.
Attn: Voluntary Corporate Actions P.O. Box 43011 Providence, Rhode Island 02940-3011 |
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Computershare Trust Company, N.A.
Attn: Voluntary Corporate Actions 150 Royall Street, Suite V Canton, Massachusetts 02021 |
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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) | | | |
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.
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Name of Tendering Institution:
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Transaction Code
Number |
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 4, 5 and 6): |
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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:
(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, 4, 5 and 6) |
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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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(Signature(s) of Holder(s) of Shares)
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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. | | | |||
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Signature:
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Date:
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By Mail:
Computershare Trust Company, N.A. Attn: Voluntary Corporate Actions P.O. Box 43011 Providence, Rhode Island 02940-3011 |
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By express mail, courier, or other expedited service:
Computershare Trust Company, N.A. Attn: Voluntary Corporate Actions 150 Royall Street, Suite V Canton Massachusetts 02021 |
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