Instructions:
Please complete the form below as needed to indicate the action desired for owned issues.
All submissions must be on the participant's letterhead and must have that participant's medallion stamp.
Use theTAB or arrow keys to toggle through the updatable fields in the document. Additionally, use the date format of mm/dd/yyyy for the date fields.
I you need a non-template form, one can be found here:
You must submit completed forms via the WINS application. A user guide to the process can be found here:
For questions or additional forms, send requests via electronic mail to:
APPRAISAL RIGHTS OR DISSENTERS’ RIGHTS
INSTRUCTION LETTER
Date: (Today’s date)
The Depository Trust Company
55 Water Street – 25th Floor
New York, NY 10041
Attn: Proxy Department
RE:(Insert description of issue with CUSIP number)
(Insert DTC Participant Account Number)
Dear Partner:
Please have your nominee, Cede & Co., sign the attached letter in order to assert appraisal rightsin connection with
(Describe event details) to be held on
(Date) or (merger) effective
(Date) with respect to
(Number of)shares of the above-referenced securitiescredited to our DTC Participant account.
The undersigned certifies to DTC and Cede & Co., that the information and facts set forth in the attached letter are true and correct, including the number of shares credited to our DTC Participant account that are beneficially owned by our customer.
Please make the letter available for pick-up by
(Firm or person responsible for picking up documents from DTC)or overnight courier to
Name of Company
Address
Address
Contact Person
The overnightcourier account number is
(Courier account number)
Very truly yours,
(Insert name of Participant)
BY: ______
Manual signature of authorized person
(Type signer’s name)
(Type signer’s title)
______
Medallion Stamp
Cede & Co.
c/o The Depository Trust Company
55 Water Street
New York, NY10041
Date: (Today’s Date)
Name of Company
Address
Address
Contact Person
Attention: Contact Person
Cede & Co., the nominee of The Depository Trust Company (“DTC”), is a holder of record of shares of
(Insert description of issue with CUSIP number)DTC is informed by its Participant,
Name of Companythat
(# of shares)sharesare beneficially owned by
Customer Name. In accordance with instructions received from Participant on behalf of its customer, we hereby assert appraisal (or dissenters’) rights with respect to the Shares.
Future correspondence on this matter should be directed to
Customer Name
(Address of customer)with copies directed to the attention of
Name of Company
Address
Address
Contact Person
Very truly yours,
Cede & Co.
BY: ______
Partner
Date :
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