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If delivering by hand, express mail, courier
or other expedited service: |
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If delivering by mail:
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Continental Stock Transfer & Trust Company
Attn: Corporate Actions 1 State Street, 30th Floor New York, New York 10004 |
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Continental Stock Transfer & Trust Company
Attn: Corporate Actions 1 State Street, 30th Floor New York, New York 10004 |
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Names(s) and Address(es) of Registered Owner(s)
(Please fill in, if blank, exactly as name(s) appear(s) on certificate(s)) |
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Certificate(s) Surrendered
(Attach additional list if necessary) |
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Certificate
Number(s) |
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Total Number of Shares
Represented By Certificate(s) |
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Total number
of shares: |
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☐
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| | CHECK HERE IF TENDERED SHARES ARE BEING DELIVERED BY BOOK-ENTRY TRANSFER TO THE ACCOUNT MAINTAINED BY THE DEPOSITARY WITH DTC AND COMPLETE THE FOLLOWING (ONLY FINANCIAL INSTITUTIONS THAT ARE PARTICIPANTS IN DTC MAY DELIVER SHARES BY BOOK-ENTRY TRANSFER): | |
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Name of Tendering
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DTC Participant
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Transaction Code
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| | CHECK HERE IF TENDERED SHARES ARE BEING DELIVERED PURSUANT TO A NOTICE OF GUARANTEED DELIVERY PREVIOUSLY SENT TO THE DEPOSITARY AND COMPLETE THE FOLLOWING (PLEASE ENCLOSE A PHOTOCOPY OF SUCH NOTICE OF GUARANTEED DELIVERY): | |
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Window Ticket Number (if any) or DTC Participant
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Date of Execution of Notice of Guaranteed
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Name of Institution which Guaranteed
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| Issue payment to: | | | | |
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(Please Print)
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(Include Zip Code)
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(Tax Identification or Social Security No.)
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| Deliver check to: | | | | |
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(Please Print)
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(Include Zip Code)
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| Dated: , 2024 | | | | |
| | Firm: | | |
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| | By: | | |
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SUBSTITUTE
FORM W-9
Department of the
Treasury Internal Revenue Service
Payer’s Request for
Taxpayer Identification Number (TIN) and Certification |
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Part 1 — PLEASE PROVIDE YOUR TIN IN THE BOX AT RIGHT AND CERTIFY BY SIGNING AND DATING BELOW
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Social Security Number
OR
Employer Identification
Number |
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Part 2 — FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING
(See Page 2 of enclosed Guidelines)
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Part 3 — Certification Under Penalties of Perjury, I certify that:
(1)
The number shown on this form is my current taxpayer identification number (or I am waiting for a number to be issued to me),
(2)
I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (the “IRS”) that I am subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding and
(3)
I am a U.S. person (including a U.S. resident alien),
(4)
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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Part 4 —
Awaiting TIN ☐
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Certification instructions — You must cross out item (2) in Part 3 above if you have been notified by the IRS that you are subject to backup withholding because of underreporting interest or dividends on your tax return. However, if after being notified by the IRS that you are subject to backup withholding you receive another notification from the IRS stating that you are no longer subject to backup withholding, do not cross out item (2).
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| SIGNATURE DATE | | | |||||||||
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| CITY STATE ZIP CODE | | | |||||||||
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PAYER’S NAME: Continental Stock Transfer & Trust Company
CERTIFICATE OF AWAITING TAXPAYER IDENTIFICATION NUMBER
I certify, under 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 before payment is made, a portion of such reportable payment will be withheld.
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Signature
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Date
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For this type of account:
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Give the SOCIAL
SECURITY number of — |
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For this type of account:
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Give the EMPLOYER
IDENTIFICATION number of — |
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1.
An individual’s account
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| | The individual | | |
8.
Sole proprietorship account
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| | The owner(4) | |
2.
Two or more individuals (joint account)
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| | The actual owner of the account or, if combined funds, the first individual on the account(1) | | |
9.
A valid trust, estate or pension trust
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| | The legal entity(5) | |
3.
Husband and wife (joint account)
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| | The actual owner of the account or, if joint funds, the first individual on the account(1) | | |
10.
Corporate account
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| | The corporation | |
4.
Custodian account of a minor (Uniform Gift to Minors Act)
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| | The minor(2) | | |
11.
Religious, charitable, or educational organization account
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| | The organization | |
5.
Adult and minor (joint account)
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| | The adult or, if the minor is the only contributor, the minor(1) | | |
12.
Partnership account held in the name of the business
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| | The partnership | |
6.
Account in the name of guardian or committee for a designated ward, minor, or incompetent person
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| | The ward, minor, or incompetent person(3) | | |
13.
Association, club, or other tax-exempt organization
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| | The organization | |
7. a.
The usual revocable savings trust account (grantor is also trustee)
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| | The grantor-trustee(1) | | |
14.
A broker or registered nominee
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| | The broker or nominee | |
b.
So-called trust account that is not a legal or valid trust under state law
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| | The actual owner(1) | | |
15.
Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments
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| | The public entity | |
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If delivering by hand, express mail, courier
or other expedited service: |
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If delivering by mail:
|
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Continental Stock Transfer & Trust Company
Attn: Corporate Actions 1 State Street, 30th Floor New York, New York 10004 |
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Continental Stock Transfer & Trust Company
Attn: Corporate Actions 1 State Street, 30th Floor New York, New York 10004 |
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