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If delivering by express mail, courier,
or other expedited service: |
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By mail:
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Equiniti Trust Company, LLC
1110 Centre Pointe Curve Suite # 101 Mendota Heights, MN 55120 Attn: Onbase — Reorganization Department |
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Equiniti Trust Company, LLC
Operations Center Attn: Onbase — Reorganization Department 1110 Centre Pointe Curve Suite # 101 Mendota Heights, MN 55120 |
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DESCRIPTION OF SHARES TENDERED
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Name(s) and Address(es) of Registered Owner(s)
(If blank, please fill in exactly as name(s) appear(s) on share certificate(s)) |
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Shares Surrendered
(attached additional list if necessary) |
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Certificated Shares**
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Certificate
Number(s)* |
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Total Number
of Shares Represented by Certificate(s)* |
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Number of
Shares Surrendered** |
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Book Entry
Shares Surrendered |
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DRIP shares
to be tendered |
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Total Shares
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*
Need not be completed by book-entry stockholders.
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**
Unless otherwise indicated, it will be assumed that all shares of common stock represented by certificates described above are being surrendered hereby.
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Name of Tendering Institution:
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DTC Participant Number:
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Transaction Code Number:
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Name(s) of Registered Owner(s):
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Window Ticket Number (if any) or DTC Participant Number:
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Date of Execution of Notice of Guaranteed Delivery:
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Name of Institution which Guaranteed Delivery:
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(Please Print)
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(Include Zip Code)
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(Tax Identification or Social Security Number)
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☐
Credit Shares tendered by book-entry transfer that are not accepted for payment to the DTC account set
forth below.
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(DTC Account Number)
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(Please Print)
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(Include Zip Code)
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(Signature(s) of Stockholder(s))
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(Please Print)
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(Include Zip Code)
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Tax Identification or
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(Include Zip Code)
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(Please Type or Print)
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Dated: , 20
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Place medallion guarantee in space below:
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If delivering by express mail, courier,
or other expedited service:
Equiniti Trust Company, LLC
1110 Centre Pointe Curve Suite # 101 Mendota Heights, MN 55120 Attn: Onbase — Reorganization Department |
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By mail:
Equiniti Trust Company, LLC
Operations Center Attn: Onbase — Reorganization Department 1110 Centre Pointe Curve Suite # 101 Mendota Heights, MN 55120 |
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