EX-99.3 8 ex99-3.txt FORM OF ELECTION AND TRANSMITTAL FORM 1 EXHIBIT 99.3
| | | FORD MOTOR COMPANY RECAPITALIZATION ELECTION ----- SHARES OF FORD MOTOR COMPANY CLASS B STOCK OWNED BY YOU: CHOICE OF ELECTION (1) in certificate form: (6) [ ] Mark this box if you wish to make a mixed or partial election and indicate the number of shares in the space provided next to the chosen election. (2) Taxpayer ID Number: (7) [ ] $20 Cash Election For Shares. You can elect to receive one share of Class B stock and $20 in cash. (3) [ ] Mark this box if you want your new Ford (8) [ ] New Stock Election For Shares. Common Stock to be issued in another You can elect to receive one share of name. (Complete Box B on the reverse new Class B stock and a fraction of a side) share of new Ford Common Stock with a value of $20 based on the average of the trading prices of Ford Common Stock during a five trading day period ending on July 28, 2000. (4) [ ] Mark this box if your Ford Class B Stock (9) [ ] Pro Rata Election For Shares. certificates which you wish to surrender You can elect to receive one share of have been lost, destroyed, mutilated new Class B stock and a combination of or stolen. Then, complete Box A below. cash and new Ford Common Stock with a value together of $20, based on the average trading prices during such (5) [ ] Mark this box if you wish to provide period. special mailing instructions for the statements and/or checks to which you may be entitled. (Complete Box C on the reverse side). ------------------------------------------------------------------------------------------------------------------------------------ THE ELECTION AND TRANSMITTAL FORM WITH THE ACCOMPANYING CERTIFICATES MUST BE RECEIVED AT EQUISERVE BY 8:30 A.M. ON AUGUST 2, 2000 ----------------------------------------------------------------------------------------------------------------------------------- You must mark either Box (7), (8), or (9) to make and Election YOU MUST COMPLETE THE SUBSTITUTE in the Recapitalization FORM W-9 ON THE REVERSE SIDE, BOX D. (10) -------------------------------------------- Signature of Owner (Date) -------------------------------------------- Signature of Co-Owner, if any (Date) --------------------- --------------------- Daytime Telephone # Evening Telephone # ----------------------------------------------------------------------------------------------------------------------------------- DO NOT DETACH - FOLD AND INSERT IN THE GREEN STRIPED ENVELOPE PROVIDED ----------------------------------------------------------------------------------------------------------------------------------- BOX A AFFIDAVIT OF LOST OR DESTROYED CERTIFICATE(S) AFFIDAVIT IS INVALID IF NOT SIGNED BELOW Complete this form only if you cannot locate some or all of your Ford Motor Company Class B Stock certificates. Please print clearly. Taxpayer ID: ---------------------------------------------------------------------- TOTAL SHARES LOST | -----------------------------------------------|---------------------- Please Fill In Certificate No(s) if Known |Number of Shares -----------------------------------------------|---------------------- | -----------------------------------------------|---------------------- | -----------------------------------------------|---------------------- | -----------------------------------------------|---------------------- | ---------------------------------------------------------------------- Attach separate schedule if needed ---------------------------------------------------------------------- I certify that I am the lawful owner of the above shares described. These shares have not been pledged or endorsed and no other person, firm, corporation, agency or government has asserted any right or title, claim equity or interest in this (these) certificate(s). I have made a diligent search for the certificate(s), and I have been unable to find it (them). I agree (for myself, my heirs, assigns and personal representatives), in consideration of the exchange of the shares represented by the certificate(s), to completely indemnify, protect and hold harmless each of GENERAL INSURANCE COMPANY OF AMERICA, Ford Motor Company, and EquiServe Trust Company and their respective affiliates collectively, from and against any and all losses, costs and damages which they may be subject to, or liable for, as enumerated in your file. I agree that this form is attached to and made part of Blanket Bond Number 5926165 underwritten by GENERAL INSURANCE COMPANY OF AMERICA to protect Ford Motor Company, and EquiServe Trust Company, and their respective affiliates. I agree to surrender the certificate(s) for its (their) cancellation if I find it (them) at any time. NOTARY REQUIRED FOR REPLACEMENT OF CERTIFICATES TOTALING 500 SHARES OR MORE AFFIDAVIT IS INVALID IF NOT SIGNED BELOW AND/OR A CHECK IS NOT INCLUDED X Signed by Affiant (stockholder) on this (date) ------------------------------------------- ------------------------------ (Deponent) (Indemnitor) (Heirs Individually) Month Day Year State of County of Notary Signature --------- -------------------------------------------------------- ---------------------------------------------- | | Printed Name of Notary | | ---------------------------------------------- | | Sworn to and subscribed to me this My Commission Expires | | -------------------------------------------------------- ---------------------------------------------- | | (Month/Day/Year) (Month/Day/Year) --------- (Notary Seal) ==================================================================================================================================== Replacement Insurance Premium Calculation for lost stock certificates. X .25 = ---------------------------------------- ---------------------------------------------------------- ------------------------- SHARES LOST INSURANCE PREMIUM PER SHARE TOTAL PREMIUM DUE Please make your check payable to GENERAL INSURANCE COMPANY OF AMERICA and enclose it with the Transmittal Form. ====================================================================================================================================
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PLEASE READ THE INSTRUCTIONS TO THE ELECTION AND -------------------------------------------------------------------------------- TRANSMITTAL FORM BEFORE COMPLETING THIS FORM. BOX D SUBSTITUTE FORM W-9 -------------------------------------------------------------------------------- By signing on the reverse side: If the Taxpayer ID Number printed on the reverse side of this Form is INCORRECT, cross it out and --> --------------------------- - I certify that I have read and understand the write in the CORRECT number here. CORRECTED TAXPAYER ID NUMBER Instructions to the Election and Transmittal -------------------------------------------------------------------------------- Form. Under penalties of perjury, I certify that: (1) the number printed on the other side of this form or the corrected - I certify that all of the representations, number above is my correct Taxpayer ID Number (or I am waiting for a warranties and agreements set forth in number to be issued to me), and (2) I am not subject to backup paragraph 10, Important Information, in the withholding because: Instructions to the Election and Transmittal (A) I am exempt from backup withholding, or (B) I have not been Form are true and correct with respect to me notified by the Internal Revenue Service (IRS) that I am subject to or with respect to the beneficial owner of backup withholding as a result of a failure to report all interest or the shares tendered hereby, and that the dividends, or (C) the IRS has notified me that I am no longer subject tendering stockholder is making these to backup withholding (you must cross out item (2) above if you have representations and warranties to Ford been notified by the IRS that you are currently subject to backup Motor Company and agreeing to the terms and withholding). conditions of the Recapitalization. M EXEMPT PAYEE ATTACH ENCLOSED IRS FORM W-8 CERTIFICATE OF FOREIGN - I certify that (i) I am eligible to STATUS (IF APPLICABLE) participate in the Recapitalization and (ii) if I am tendering shares on behalf of a X Signature Date: beneficial owner, to the best of my -------------------------------------------------------------------------------- knowledge, such person is eligible to participate in the Recapitalization. -------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ BOX B BOX C TO TRANSFER OWNERSHIP SPECIAL MAILING INSTRUCTIONS ------------------------------------------------------------------------------------------------------------------------------------ If you want your new Ford Common Stock Signature Guarantee Medallion | Fill in ONLY if mailing to someone other and/or check to be issued in another | than the undersigned or to the name, fill in this section with the | undersigned at an address other than information for the new account name. If | that shown on the front of this card. you want multiple accounts, list them on | Mail statement(s) and/or check(s) to: a separate sheet. | | --------------------------------------------- ----------------------------------------| -------------------------------------------- Name(Please Print First, Middle & Last Name) (Title of Officer Signing this Guarantee)| Name(Please Print First, Middle & Last Name) | --------------------------------------------- ----------------------------------------| -------------------------------------------- Address (Number and Street) (Name of Guarantor - Please Print) | Address (Number and Street) | --------------------------------------------- ----------------------------------------| ------------------------------------------- (City, State & Zip Code) (Address of Guarantor Firm) | | --------------------------------------------- ----------------------------------------| ------------------------------------------- (Tax Identification or Social Security Number) | (City, State & Zip Code) | ------------------------------------------------------------------------------------------------------------------------------------
YOU MUST RETURN YOUR CLASS B STOCK CERTIFICATE(S) WITH YOUR COMPLETED ELECTION AND TRANSMITTAL FORM AND ANY OTHER REQUIRED DOCUMENTS TO THE ADDRESS BELOW BEFORE 8:30 A.M. ON AUGUST 2, 2000. MAILING ADDRESS BY MAIL: BY OVERNIGHT COURIER: BY HAND: EquiServe EquiServe EquiServe P.O. Box 832004 Attn: Ford Motor Company c/o Securities Transfer & Boston, MA02283-2004 40 Campanelli Drive Reporting Services, Inc. Braintree, MA02184 Attn: Corporate Actions 100 William Street, Galleria New York, NY10038 DELIVERY OF THE ELECTION AND TRANSMITTAL FORM TO AN ADDRESS OTHER THAN AS SET FORTH ABOVE WILL NOT CONSTITUTE A VALID DELIVERY TO THE EXCHANGE AGENT. BY MAIL, RETURN IN THE GREEN STRIPED ENVELOPE. DO NOT USE THE WHITE BALLOT ENVELOPE. Call 1 800 243 7812 with questions IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE INFORMATION AGENT, GEORGESON SHAREHOLDER COMMUNICATIONS, AT 1-800-243-7812. (U.S. AND CANADA) OR 00-44-207-335-7281 (OUTSIDE OF THE U.S. AND CANADA). BANKS, BROKERS AND OTHER INSTITUTIONS, PLEASE CALL 1-212-440-9800 (COLLECT). IF YOU HAVE LOST CERTIFICATES VALUED AT $100,000 OR MORE, PLEASE CALL 1-800-279-1237 FOR ADDITIONAL INSTRUCTIONS.