LETTER OF TRANSMITTAL
TO ACCOMPANY CERTIFICATE(S) OF
WHEELER REAL ESTATE INVESTMENT TRUST, INC.
SERIES A PREFERRED STOCK AND/OR
SERIES B PREFERRED STOCK
THE EXCHANGE OFFER BY WHEELER REAL ESTATE INVESTMENT TRUST, INC. (THE COMPANY), THE TERMS AND CONDITIONS OF WHICH ARE SET FORTH IN THE PROSPECTUS DATED JUNE 15, 2015 (THE PROSPECTUS), WILL EXPIRE AT 11:59 P.M., NEW YORK CITY TIME, ON JULY 13, 2015, UNLESS EXTENDED OR EARLIER TERMINATED BY US (THE EXPIRATION DATE). IF A BROKER, DEALER, COMMERCIAL BANK, TRUST COMPANY OR OTHER NOMINEE LEGALLY OWNS SERIES A PREFERRED STOCK AND/OR SERIES B PREFERRED STOCK (COLLECTIVELY THE PREFERRED STOCK), SUCH NOMINEE MAY HAVE AN EARLIER DEADLINE FOR ACCEPTING THE OFFER. YOU SHOULD PROMPTLY CONTACT THE BROKER, DEALER, COMMERCIAL BANK, TRUST COMPANY OR OTHER NOMINEE THAT HOLDS YOUR SHARES OF PREFERRED STOCK TO DETERMINE ITS DEADLINE. IN ORDER TO BE ELIGIBLE TO RECEIVE SHARES OF COMPANY COMMON STOCK (THE COMMON STOCK) OFFERED UPON TENDER OF THE PREFERRED STOCK PURSUANT TO THE EXCHANGE OFFER, YOU MUST TENDER AND NOT WITHDRAW SHARES OF SERIES A PREFERRED STOCK OR SERIES B PREFERRED STOCK PRIOR TO THE EXPIRATION DATE. YOU MAY WITHDRAW SHARES OF PREFERRED STOCK TENDERED IN THE EXCHANGE OFFER AT ANY TIME PRIOR TO THE EXPIRATION DATE. YOU SHOULD CAREFULLY REVIEW THE PROCEDURES FOR TENDERING SHARES OF PREFERRED STOCK IN THE PROSPECTUS.
The Information Agent for the Exchange Offer is:
480 Washington Blvd., 26th Floor
Jersey City, NJ 07310
Call Toll-Free: (866) 391-7007
Or Via Email: Wheeler@georgeson.com
Please mail or deliver this properly completed Letter of Transmittal, together with the certificate(s) and any other documentation required by this Letter of Transmittal, to the Exchange Agent at one of the addresses listed below:
The Exchange Agent for the Exchange Offer is:
Computershare Trust Company, N.A.
By Mail: Computershare Trust Company, N.A. c/o Voluntary Corporate Actions P.O. Box 43011 Providence, RI 02940-3011 |
By Overnight Delivery: Computershare Trust Company, N.A. c/o Voluntary Corporate Actions 250 Royall Street, Suite V Canton, MA 02021 |
DELIVERY OF THE LETTER OF TRANSMITTAL TO AN ADDRESS OTHER THAN AS SET FORTH ABOVE WILL NOT CONSTITUTE A VALID DELIVERY TO THE EXCHANGE AGENT
THE SHARE CONSIDERATION TO BE ISSUED IN ACCORDANCE WITH THE INSTRUCTIONS HEREIN WILL BE SENT TO THE ADDRESS OF RECORD UNLESS OTHERWISE INSTRUCTED BELOW.
Complete boxes B, C (if required) below ONLY if the share consideration is to be issued to the registered holder(s) but sent to an address other than listed above or is to be issued to a person other than the registered holder(s).
DESCRIPTION OF SHARES SURRENDERED (Please fill in. Describe Series. Attach separate schedule if needed. | ||||
Name(s) and Address of Registered Holder(s) If there is any error in the name or address shown below, please make the necessary corrections. |
Certificate No. (if applicable) or Number of Shares Surrendered and held in Book Entry Form |
Number of Shares | ||
TOTAL SHARES |
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SIGNATURES MUST BE PROVIDED BELOW
PLEASE READ THE ACCOMPANYING INSTRUCTIONS CAREFULLY
Ladies and Gentlemen:
Upon the terms and subject to the conditions set forth in the Prospectus and this Letter of Transmittal, the undersigned hereby: (i) tenders to the Company the shares of Preferred Stock set forth in the box above entitled Description of Shares Surrendered; (ii) subject to and effective upon acceptance for exchange of the shares of Preferred Stock tendered herewith, irrevocably constitutes and appoints the Exchange Agent as the undersigneds true and lawful agent and attorney-in-fact with respect to any such tendered shares of Preferred Stock, with full power of substitution and resubstitution (such power of attorney being deemed to be an irrevocable power coupled with an interest) to (a) deliver certificates representing such shares of Preferred Stock, or transfer ownership of such shares of Preferred Stock on the account books maintained by DTC, together, in any such case, with all accompanying evidences of transfer and authenticity, to the Company, (b) present such shares of Preferred Stock for transfer on the relevant security register and (c) receive all benefits or otherwise exercise all rights of beneficial ownership of such shares of Preferred Stock (except that the Exchange Agent will have no rights to, or control over, the shares of Common Stock issued in respect of such shares of Preferred Stock, except as the undersigneds agent, all in accordance with the terms of the Exchange Offer); (iii) requests that Common Stock issued in exchange for tendered shares of Preferred Stock in connection with the Exchange Offer be issued to the order of the undersigned; and (iv) requests that any shares of Preferred Stock representing liquidation preference not tendered or not accepted for exchange be credited to such DTC participants account or be returned to the undersigned.
The undersigned hereby acknowledges receipt of the Prospectus and this Letter of Transmittal, which together constitute the Companys offer to exchange up to 20,853,250 newly issued shares of Common Stock for issued and outstanding shares of Preferred Stock that are validly tendered and not validly withdrawn in the Exchange Offer.
The undersigned hereby represents and warrants that: (i) the undersigned has full power and authority to tender, sell, assign and transfer the shares of Preferred Stock tendered hereby; and (ii) upon its acceptance of any tendered shares of Preferred Stock, the Company will acquire good and unencumbered title thereto, free and clear of all liens, restrictions, charges and encumbrances and that such shares of Preferred Stock will not be subject to any adverse claim.
Subject to and effective upon acceptance for exchange of, and issuance of shares of Common Stock for, the shares of Preferred Stock tendered herewith, the undersigned hereby: (i) irrevocably, sells, transfers, conveys and assigns to or upon the order of the Company, all right, title and interest in and to the shares of Preferred Stock tendered hereby; (ii) waives any and all other rights with respect to such shares of Preferred Stock (including with respect to any existing or past and defaults and their consequences in respect of such shares of Preferred Stock); (iii) releases and discharges the Company from any and all claims that the undersigned may have now, or may have in the future, arising out of, or related to, such shares of Preferred Stock, including any claims that the undersigned is entitled to receive additional payments with respect to such shares of Preferred Stock or to participate in any redemption of such shares of Preferred Stock.
The undersigned acknowledges and agrees that upon acceptance for exchange of the shares of Preferred Stock tendered herewith, without any further action, all other powers of attorney, proxies and consents given by the undersigned with respect to such shares of Preferred Stock or the Common Stock to be received in exchange for such shares of Preferred Stock will be revoked and no subsequent powers of attorney, proxies, consents or revocations may be given by the undersigned (and, if given, will not be effective), except for powers of attorney, proxies, consents or revocations contemplated hereby. The undersigned will, upon request, execute and deliver any additional documents deemed by the Company to be necessary or desirable: to complete the sale, assignment and transfer of the shares of Preferred Stock tendered hereby. All authority conferred or agreed to be conferred in
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this Letter of Transmittal and every obligation of the undersigned hereunder shall be binding upon the successors, assigns, heirs, executors, administrators, trustees in bankruptcy and legal representatives of the undersigned and shall not be affected by, and shall survive, the death or incapacity of the undersigned. This tender may be withdrawn only in accordance with the procedures set forth in the section of the Prospectus entitled The Exchange OfferWithdrawal of Tenders.
The undersigned hereby agrees that: (i) no tender of shares of Preferred Stock is valid until any defect or irregularity in connection with tenders of shares of Preferred Stock is cured within such time as the Company determines, unless waived by the Company; (ii) none of the Company, the Exchange Agent, the Information Agent, the Dealer Managers (as defined in the Prospectus) or any other person is under any duty to give notification of any defects or irregularities in the tenders of shares of Preferred Stock or will incur any liability to holders for failure to give any such notification; (iii) a tender of shares of Preferred Stock will constitute a binding agreement between us upon the terms and subject to the conditions of the Exchange Offer; and (iv) all questions as to the form of documents (including notices of withdrawal) and the validity, form, eligibility (including time of receipt) and acceptance for exchange of any tender of shares of Preferred Stock will be determined by the Company in its sole discretion and such determination shall be final and binding.
The undersigned shall indemnify and hold harmless each of the Company, the Information Agent and Exchange Agent (each, an Indemnified Party) against any losses, claims, damages or liabilities, joint or several, to which any Indemnified Party may become subject, insofar as such losses, claims, damages or liabilities (or actions in respect thereof) arise out of or are based upon a breach of the foregoing representations and warranties and will reimburse any Indemnified Party for any legal or other expenses reasonably incurred by such Indemnified Party in connection with investigating or defending any such action or claim as such expenses are incurred.
IMPORTANT
STOCKHOLDER: SIGN HERE
(PLEASE COMPLETE AND RETURN THE IRS FORM W-9 INCLUDED IN THIS LETTER OF
TRANSMITTAL OR AN APPLICABLE IRS FORM W-8)
Signature(s) of Holder(s) of Shares
Must Sign Above
Dated:
Name(s)
(Please Print)
Capacity (full title) (See Instruction 6)
Address
(Include Zip Code)
Must be signed by registered holder(s) exactly as name(s) appear(s) on Preferred Stock share certificate(s) or on a security position listing or by person(s) authorized to become registered holder(s) by Share Certificates and documents transmitted herewith. If signature is by a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or other person acting in a fiduciary or representative capacity, such person must set forth his or her full title under Capacity and submit evidence satisfactory to the Company of such persons authority to so act.
APPLY MEDALLION GUARANTEE STAMP BELOW
(IF REQUIREDSEE INSTRUCTION 3)
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DTC: DTC has confirmed that the Exchange Offer is eligible for DTCs Automated Tender Offer Program (ATOP). Accordingly, if you hold your shares of Preferred Stock in street name, you may, instead of physically completing and signing the Transmittal Letter and delivering it to the Exchange Agent, electronically transmit their acceptance of the Exchange Offer by causing DTC to transfer Series A and Series B Preferred Stock to the Exchange Agent in accordance with DTCs ATOP procedures for transfer. DTC will then send an agents message to the Exchange Agent.
YOUR BANK OR BROKER CAN ASSIST YOU IN COMPLETING THIS FORM. THE INSTRUCTIONS INCLUDED WITH THIS LETTER OF TRANSMITTAL MUST BE FOLLOWED. QUESTIONS AND REQUESTS FOR ASSISTANCE OR FOR ADDITIONAL COPIES OF THE PROSPECTUS AND THIS LETTER OF TRANSMITTAL MAY BE DIRECTED TO THE INFORMATION AGENT.
Delivery of this Letter of Transmittal and Certificates. All physically delivered Series A and Series B Preferred Stock or confirmation of any book-entry transfer to the Exchange Agents account at DTC, as well as a properly completed and duly executed copy of this Letter of Transmittal (or facsimile thereof), and any other documents required by this Letter of Transmittal with any required signature guarantees or, in the case of a book-entry transfer, an appropriate agents message, must be received by the Exchange Agent at its address set forth herein on or prior to the Expiration Date. The method of delivery of this Letter of Transmittal, the Series A and Series B Preferred Stock and all other required documents is at the election and risk of the holder. Instead of delivery by mail, it is recommended that holders use an overnight or hand delivery service.
Any beneficial holder whose Series A and Series B Preferred Stock are registered in the name of a broker, dealer, commercial bank, trust company or other nominee and who wishes to tender Series A and Series B Preferred Stock in the Exchange Offer should contact such registered holder promptly and instruct such registered holder to tender on such beneficial holders behalf. If such beneficial holder wishes to tender directly, such beneficial holder must, prior to completing and executing the Transmittal Letter and tendering Series A and Series B Preferred Stock, either make appropriate arrangements to register ownership of the Series A and Series B Preferred Stock in such beneficial holders own name or obtain a properly completed bond power from the registered holder. Beneficial holders should be aware that the transfer of registered ownership may take considerable time.
The Company expressly reserves the right, at any time or from time to time, to extend the Expiration Date by complying with certain conditions set forth in the prospectus.
The method of delivery of this Letter of Transmittal, the Series A and Series B Preferred Stock and all other required documents, including delivery through DTC and acceptance of an agents message transmitted through ATOP, is at the option and risk of the tendering holder. If delivery is by mail, registered mail with return receipt requested, properly insured, is recommended. In all cases, sufficient time should be allowed for such documents to reach the DTC.
Waiver of Conditions. The Company reserves the absolute right to waive, in whole or in part, certain specified conditions to the Exchange Offer set forth in the prospectus. The condition that the registration statement of which the prospectus forms a part being declared effective and no stop order suspending its effectiveness or any proceeding for that purpose being outstanding may not be waived by us.
Requests for Assistance or Additional Copies. Questions and requests for assistance relating to the Prospectus, this Letter of Transmittal and other related documents and relating to the procedure for tendering may be directed to the Exchange Agent at the address and telephone number set forth above.
Questions and requests for assistance or for additional copies of the prospectus may be directed to the Information Agent at the address and telephone number set forth above.
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Validity and Form. All questions as to the validity, form, eligibility (including time of receipt) and acceptance of tenders and withdrawals of Series A and Series B Preferred Stock will be determined by the Company in its sole discretion, which determination will be final and binding. The Company reserves the absolute right to reject any and all tenders of Series A and Series B Preferred Stock that are not in proper form or the acceptance of which would, in the opinion of counsel for the Company, be unlawful. The Company reserves the absolute right to waive any irregularities or defects as to particular Series A and Series B Preferred Stock either before or after the Expiration Date, whether or not similar defects or irregularities are waived in the case of other holders of Series A and Series B Preferred Stock. The Companys interpretation of the terms and conditions of the Exchange Offer (including the instructions in this Letter of Transmittal) will be final and binding on all parties. Unless waived, any defects or irregularities in connection with tenders of Series A and Series B Preferred Stock must be cured within such time as the Company shall determine. None of the Company, the Information Agent, the Exchange Agent, the Dealer Managers nor any other person shall be under any duty to give notification of defects or irregularities with respect to tenders of Series A and Series B Preferred Stock, nor shall any of them incur any liability for failure to give such notification. Tenders of Series A and Series B Preferred Stock will not be deemed to have been made until such irregularities have been cured or waived. Any Series A and Series B Preferred Stock received by the Exchange Agent that are not properly tendered, and as to which the defects or irregularities have not been cured or waived, will be returned without cost to such holder by the Exchange Agent to the tendering holders of Series A and Series B Preferred Stock, unless otherwise provided herein, as soon as practicable following the Expiration Date.
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THE SHARE CONSIDERATION TO BE ISSUED IN ACCORDANCE WITH THE INSTRUCTIONS HEREIN WILL BE SENT TO THE ADDRESS OF RECORD UNLESS OTHERWISE INSTRUCTED BELOW.
Complete boxes A and/or B (if required) below ONLY if the share consideration is to be issued to the registered holder(s) but sent to an address other than listed above or is to be issued to a person other than the registered holder(s). Complete box C below ONLY if you complete Box A (the consideration is to be issued to a person other than the registered holder).
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INSTRUCTIONS FOR SURRENDERING SHARES
(Please read carefully the instructions below)
1. Method of Delivery: You must send or deliver your certificate(s), and this properly completed Letter of Transmittal, to the Exchange Agent to one of the addresses shown on the front page of the Letter of Transmittal. The method of delivery of certificate(s) or statement of ownership to be surrendered to the Exchange Agent is at the option and risk of the surrendering stockholder. Delivery will be deemed effective only when received. If the certificate(s) or the statement of ownership is (are) sent by mail, registered mail with return receipt requested and proper insurance is suggested.
2. Consideration to be Issued in the Same Name: If you would like the consideration to be issued in the same name as the surrendered shares are registered, complete and sign this Letter of Transmittal exactly as the surrendered shares are registered. Do not sign the surrendered certificate(s). Signature guarantees are not required if the shares surrendered herewith are (i) submitted by the registered holder(s) of such shares who has not completed the section entitled Box A: Special Issuance Instructions, or (ii) for the account of an Eligible Institution. If any of the shares surrendered hereby are owned by two or more joint owners, all such owners must sign this Letter of Transmittal exactly as written on the face of the certificate(s) or in the statement of ownership. If any shares are registered in different names, it will be necessary to complete, sign and submit a separate Letter of Transmittal for each different registration. Trustees, executors, administrators, guardians, attorneys-in-fact, officers of corporations, or others executing Letters of Transmittal in a fiduciary or representative capacity who are not identified as such in the registration must submit proper evidence of the signers authority to act.
3. Consideration to be Issued in a Different Name: If you would like the consideration to be issued in a name or names which differ from the name(s) on the certificate(s) or the statement of ownership, complete the sections entitled Box A: Special Issuance Instructions and Box C: Signatures Guarantee (If Required) and have the signatures guaranteed on this Letter of Transmittal by a firm that is a bank, broker, dealer, credit union, savings association or other entity which is an Eligible Institution. If you would like the share consideration to be issued in the name of a person other than the signer of this Letter of Transmittal, or for the consideration to be issued to a person other than the registered owner(s), then the surrendered certificate(s) must be properly endorsed or accompanied by duly executed stock power(s), or the statement of ownership must be accompanied by duly executed stock power(s), as the case may be, in each case signed exactly as the name(s) of the registered owners appear on such certificate(s) or statement of ownership, with the signatures on the certificate(s) or stock power(s) guaranteed by an Eligible Institution.
4. Special Delivery Instructions: In the section entitled Box C: Special Delivery Instructions, indicate the name and address to which the consideration is to be sent if different from the name and/or address of the person(s) signing this Letter of Transmittal.
5. Lost, Stolen, Misplaced or Destroyed Certificate(s): If your certificate(s) have been lost, stolen, misplaced or destroyed, please complete the bond on page 9 of this Letter of Transmittal.
6. Important Information Regarding Taxes: Each shareholder that submits this Letter of Transmittal (or any person submitting this Letter of Transmittal on behalf of a shareholder) is required to provide the Exchange Agent with the shareholders correct Taxpayer Identification Number (TIN), generally the shareholders social security or U.S. federal employer identification number, on the Substitute Form W-9 provided below, or, alternatively, to establish another basis for exemption from backup withholding. Item (2) in the Certification box of the Substitute Form W-9 must be crossed out if the shareholder is subject to backup withholding. In addition to potential penalties, failure to provide the correct information on the Substitute Form W-9 may subject the shareholder to 28% U.S. federal income tax backup withholding on any reportable payments made to such shareholder. If the shareholder has not been issued a TIN and has applied for one or intends to apply for one in the near future, such shareholder should write Applied For in the space provided for the TIN in Part I of the Substitute Form W-9, and sign and date the Substitute Form W-9 and the Certificate of Awaiting Taxpayer
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Identification Number. If Applied For is written in Part I and the Exchange Agent is not provided with a TIN by the time of payment, the Exchange Agent will withhold 28% from any payments of the purchase price to such shareholder. A shareholder that is not a United States person may qualify as an exempt recipient by submitting to the Exchange Agent a properly completed Form W-8BEN, Form W-8ECI or Form W-8IMY, as applicable (which the Exchange Agent will provide upon request) signed under penalty of perjury, attesting to that shareholders exempt status.
The signature and date endorsed on the Substitute Form W-9 will serve to certify that the TIN and withholding information provided in your Election Form are true, correct and complete. See the attached Guidelines for Certification of Taxpayer Identification Number on Substitute Form W-9 for additional instructions.
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Lost Securities Affidavit
IF YOU CANNOT LOCATE SOME OR ALL OF YOUR CERTIFICATE(S), PLEASE COMPLETE THE BELOW
AFFIDAVIT SAFECO INSURANCE COMPANY OF AMERICA
LOST SECURITIES AFFIDAVIT FOR ACCOUNTS WITH LESS THAN $250,000.00 IN MARKET VALUE
By checking the lost certificates box and signing the bottom of this form, I (we) certify that (a) I (we) am (are) the lawful owner(s) (Owner) of the shares described on the front of this form; (b) I (we) reside at the address set forth on the front of this form; (c) I (we) am (are) entitled to possession of the lost certificate(s) (the Lost Securities); (d) the Lost Securities have been lost, mislaid, stolen or destroyed and cannot now be produced; (e) the Lost Securities WERE NOT ENDORSED and neither the Lost Securities nor the Owner(s) rights therein have, in whole or in part, been cashed, negotiated, sold, transferred, hypothecated, pledged, disposed of, and to my (our) knowledge, no claim of right, like or interest, adverse to the Owner, in or to the Lost Securities, has been made or advanced by any person; (f) I (we) have made or caused to be made a diligent search for the Lost Securities and have been unable to find or recover the Lost Securities; (g) I (we) make this Affidavit of Lost Securities For Computershare Accounts for the purpose of inducing the issuance of new or replacement Securities (Replacement Securities) (in book-entry form, unless unavailable through the issuer) in lieu of the said Lost Securities, or the distribution to the Owner(s) of proceeds (including liquidation) thereof; and (h) I (we) agree that this Lost Securities Affidavit for Computershare Accounts may be delivered to and made part of the Safeco Insurance Company of America Bond No. 5926165.
The Owner(s) hereby agree(s) in consideration of (1) the issuance of such replacement Securities in lieu of the Lost Securities, or of the distribution to the Owner of the proceeds there from, and (2) the assumption by Safeco Insurance Company of America of liability therefore under its Bond, the OWNER, his/her/its heirs, successors and assigns agree to indemnify, protect and save harmless Safeco Insurance Company of America, Computershare Inc., Computershare Trust Company, N.A. and the issuer, jointly and severally, and their respective agents, representatives, successors, and assigns, from and against all losses, cost and damages (court costs and attorneys fees) to which they may be subject or liable arising out of or relating to the Lost Securities, the issuance of Replacement Securities, the Owners requested action herein (or any other action arising out of or relating to the Replacement of Lost Securities), or Safeco Insurance Company of Americas assumption of liability under its bond described above.
STEP 1. CALCULATE LOST CERTIFICATE BOND PREMIUM - FEE MUST BE ENCLOSED
LOST CERTIFICATE BOND PREMIUM CALCULATION: |
X
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$35.25
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=
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+
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$50.00 processing fee
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=
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Shares Lost | Bond premium Per share | Total Premium Due (MINIMUM $20.00) |
Total Check Amount |
Multiply the number of shares lost by the Safeco Insurance Company of America Bond premium noted above to calculate the premium you owe. If you have Lost Securities representing 1 or fewer shares, there is a minimum premium of $20.00. The premium is only valid until December 15, 2015. There is also a processing fee of $50.00. PLEASE MAKE YOUR CHECK PAYABLE TO COMPUTERSHARE FOR THE BOND PREMIUM AND PROCESSING FEE AND ENCLOSE WITH THIS AFFIDAVIT. If your request is approved, Computershare will forward the Bond premium to Safeco Insurance Company of America. We cannot complete your exchange without a Surety Bond. NOTE: This premium is calculated based upon each lost share, not per each lost certificate.
STEP 2. SIGNATURES OF OWNERS - all registered owners MUST sign below exactly as the name(s) appear on the front of this form
If your lost certificate(s) is (are) part of an estate or trust, or are valued at more than $250,000, please contact Computershare for additional instructions.
ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Signature of owner |
Signature of Co-Owner, if any |
STEP 3. NOTARIZATION
You must have your signature(s) notarized if you have lost more than 1 shares.
State of County of Notary Signature
Printed Name of Notary Sworn to and subscribed to me this (date) (month/day/year)
My commission Expires (date) (month/day/year) (Notary Seal)
Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service |
Request for Taxpayer Identification Number and Certification |
Give Form to the requester. Do not |
Print or type See Specific Instructions on page 2.
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1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
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2 Business name/disregarded entity name, if different from above
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3 Check appropriate box for federal tax classification; check only one of the following seven boxes: |
4 Exemptions (codes apply only
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained | |||||||||||||||||||||||||
¨ | Individual/sole proprietor or single-member LLC |
¨ | C Corporation | ¨ | S Corporation | ¨ | Partnership | ¨ | Trust/estate | |||||||||||||||||
¨ |
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) u
Note. For a single-member LLC that is disregarded, do not check LLC;
check the appropriate box in the line above for the tax |
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¨ |
Other (see instructions) u |
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5 Address (number, street, and apt. or suite no.)
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Requesters name and address (optional) | |||||||||||||||||||||||||
6 City, state, and ZIP code
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7 List account number(s) here (optional)
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Part I | Taxpayer Identification Number (TIN) |
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. |
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Social security number | ||||||||||||||||||
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or | ||||||||||||||||||
Employer identification number | ||||||||||||||||||
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Part II | 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 because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and |
3. | I am a U.S. citizen or other U.S. person (defined below); and |
4. | The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. |
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign Here |
Signature of U.S. person u |
Date u |
Cat. No. 10231X | Form W-9 (Rev. 12-2014) |
Form W-9 (Rev. 12-2014) |
Page 2 |
Form W-9 (Rev. 12-2014) |
Page 3 |
Form W-9 (Rev. 12-2014) |
Page 4 |
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.