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DELIVER BY MAIL TO: AMERICAN STOCK TRANSFER DELIVER IN PERSON TO:
AMERICAN STOCK TRANSFER AND TRUST COMPANY AMERICAN STOCK TRANSFER
AND TRUST COMPANY AND TRUST COMPANY
40 WALL STREET LETTER OF TRANSMITTAL 40 WALL STREET-46TH FLOOR
NEW YORK, NY 10005 NEW YORK, NY 10005
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ACCOUNT NUMBER
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NUMBER OF SHARES CUSIP NUMBER
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LIST ALL CERTIFICATES SUBMITTED
CERTIFICATE NUMBER SHARES CERTIFICATE NUMBER SHARES
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PLEASE READ THE ACCOMPANYING INSTRUCTIONS CAREFULLY. SIGN ON THE REVERSE SIDE
AND COMPLETE THE W-9 FORM BELOW.
REGISTRATION
IF CERTIFICATES AND/OR CHECKS ARE TO BE ISSUED IN A NAME OTHER THAN [ ]
THAT SHOWN AT THE TOP OF THIS FORM OR ARE TO BE SENT TO AN ADDRESS
OTHER THAN THAT SHOWN AT THE TOP OF THIS FORM, PLEASE CHECK THE BOX AT
THE RIGHT AND COMPLETE THE INFORMATION ON THE REVERSE SIDE OF THIS
FORM.
LOST CERTIFICATES
IF YOUR SECURITIES HAVE BEEN EITHER LOST OR DESTROYED, PLEASE GIVE
WRITTEN NOTIFICATION TO AMERICAN STOCK TRANSFER AND TRUST COMPANY, 40
WALL ST., NEW YORK, NY 10005, ATTENTION: LOST SECURITIES DEPT.
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SUBSTITUTE FORM W-9 REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION
(PLEASE REFER TO ACCOMPANYING GUIDELINES)
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PART 1 - PLEASE ENTER YOUR
SOCIAL SECURITY NUMBER OR ==========> | | | | | | | | | |
EMPLOYER IDENTIFICATION NUMBER
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PART 2 - CERTIFICATION - Under Penalties of Perjury, I certify that:
(1) The number shown on this form is my correct Taxpayer Identification Number
(or I am waiting for a number to be issued to me) and
(2) I am not subject to backup withholding either because I have not been
notified by the Internal Revenue Service ("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.
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Certificate Instructions - You may cross out item (2) in Part 2 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 were subject to backup withholding you
received another notification from the IRS stating that you are no longer
subject to backup withholding, do not cross out Item (2).
PART 3 - CERTIFICATION FOR FOREIGN
RECORD HOLDERS
Under penalties of perjury, I certify that I am not a United States citizen
or resident (or I am signing for a foreign corporation, partnership, estate
or trust).
SIGNATURE
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DATE
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SIGNATURE DATE
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NOTE: FAILURE TO COMPLETE AND RETURN THIS SUBSTITUTE FORM W-9 MAY RESULT IN
BACKUP WITHHOLDING OF 31% OF ANY PAYMENTS MADE TO YOU.
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SPECIAL ISSUANCE INSTRUCTIONS
(SEE INSTRUCTIONS)
To be completed ONLY if certificate(s) and/or check(s) are to be issued in the
name of someone other than the registered holder(s)
NAME:
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ADDRESS:
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EMPLOYER IDENTIFICATION OR
SOCIAL SECURITY NUMBER
[ ]
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SPECIAL DELIVERY INSTRUCTIONS
(SEE INSTRUCTIONS)
To be completed ONLY if certificate(s) and/or check(s) are to be mailed to
someone other than the registered holder(s), or to such registered holder(s) at
an address other than shown on the reverse side of this form.
NAME:
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ADDRESS:
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SIGN HERE
SIGNATURE(S) OF
STOCKHOLDER(S)
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DATED:
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Must be signed by registered holder(s) exactly as name(s) appear(s) on the
Certificate(s) or a security position listing or by person(s) authorized to
become registered holder(s) by certificates and documents transmitted herewith.
If signature is by a trustee, executor, administrator, guardian,
attorney-in-fact, officer of a corporation or other person acting in a fiduciary
or representative capacity, please set forth the following information and see
instructions.
NAME(S)
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CAPACITY (full title)
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ADDRESS
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AREA CODE AND TELEPHONE NO
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GUARANTEE OF SIGNATURE(s)
(SEE INSTRUCTIONS)
NAME OF FIRM
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ADDRESS
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AUTHORIZED SIGNATURE
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NAME
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AREA CODE AND TELEPHONE NO
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