EX-99.6 9 nomineeholder.htm FORM OF NOMINEE HOLDER CERTIFICATION
Exhibit 99.6
FORM OF
NOMINEE HOLDER CERTIFICATION
CYTORI THERAPEUTICS, INC.
The undersigned, a bank, broker, dealer, trustee, depositary, or other nominee of non-transferable subscription rights (the "Subscription Rights") to purchase units ("Units") of Cytori Therapeutics, Inc. (the "Company"), said Units each comprised of one share of common stock ("Common Stock") and [___] of a warrant to purchase one share of Common Stock (a "Warrant") pursuant to the Subscription Rights offering described and provided for in the Company's Prospectus dated [______], 2016, hereby certifies to the Company and Broadridge Corporate Issuer Solutions, Inc., as Subscription Agent for such Rights Offering, that (1) the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the number of Subscription Rights on the terms and subject to the conditions set forth in the Prospectus specified below pursuant to the Basic Subscription Right (as defined in the Prospectus) and, on behalf of beneficial owners of Subscription Rights who have subscribed for the purchase of additional Units pursuant to the Over-Subscription Privilege (as defined in the Prospectus), the number of Units specified below, listing separately below each such exercised Basic Subscription Right and the corresponding Over-Subscription Privilege (without identifying any such beneficial owner), and (2) to the extent a beneficial owner has elected to subscribe for Units pursuant to the Over-Subscription Privilege, each such beneficial owner's Basic Subscription Right has been exercised in full:
Number of Shares Owned
on the Record Date
 
Individual
Soliciting
Broker
(if any)
 
Number of Units Subscribed for
Pursuant to the
Basic Subscription Right
 
Number of Units Subscribed for
Pursuant to the
Over-Subscription Privilege
1.
 
2.
 
3.
 
4.
 
5.
 
6.
 
7.
 
 
 
Name of Nominee Holder
     
   
By:
 
 
 
     
Name:
 
 
 
     
Title:
 
 
 
     
     
   
Phone Number:
 
 
 
     
Fax Number:
 
 
 
     
   
Dated:
 
 
 
 
 

Provide the following information, if applicable:
 
 
 
DTC Participant Number
     
 
 
 
DTC Participant
   
     
     
   
By:
 
 
 
     
Name:
 
 
 
     
Title:
 
 
 
     
 
 
 
DTC Basic Subscription
Confirmation Number(s)
     
   
Dated: