Special Payment Instructions. (If applicable—see item 4 of Instructions) To be completed ONLY if cash payments are to be mailed to a recipient OTHER than the registered holder(s). Stock must be properly assigned and signatures guaranteed. For additional payment instructions, please attach additional sheet. Mail cash payments to (please print): Name: Address: (Zip Code) Taxpayer Identification or Social Security Number of Recipient: * The Medallion Signature Guarantee, above, must also be completed if you designate Special Payment Instructions.
Special Payment Instructions. Indicate any particulars, special instructions or references to facilitate payment or identification of payment.
Special Payment Instructions. Provide new payee information in Box D if different than those listed in Box C. A Medallion Guarantee is required. Please see Instruction No. 2. Failure to provide the required documentation will result in payment being issued to the registered Warrantholder(s) as shown in Box C.
Special Payment Instructions. If checks or certificates representing Provident Financial Services, Inc. common stock are to be payable to the order of or registered is other than exactly the name(s) that appear(s) on the certificate(s) representing shares of First Sentinel Bancorp, Inc. common stock being submitted herewith, the certificate(s) submitted herewith must be endorsed, or accompanied by appropriate signed stock power(s), and the signature(s) appearing on such endorsement(s) or stock power(s) and on this Election Form must be guaranteed by an eligible financial institution or broker who is a member/participant in a Medallion Program approved by the Securities Transfer Association, Inc. Please also check the appropriate box in “Special Payment Instructions” on the Election Form.
Special Payment Instructions. Provide new payee information in Box C if different than listed on page 2 of this Letter of Transmittal. A Medallion Guarantee is required. Please see Instruction No. 2. Failure to provide the required documentation will result in payment being issued to the registered Security Interests Holder(s) as shown on page 2 of this Letter of Transmittal.
Special Payment Instructions. If check or certificates representing FirstBank common stock are to be payable to the order of or registered in other than exactly the name(s) that appear(s) on the certificate(s) representing shares of Oregon Trail common stock being submitted herewith, the certificate(s) submitted herewith must be endorsed, or accompanied by appropriate signed stock power(s), and the signature(s) appearing on such endorsement(s) or stock power(s) and on this Election Form and Letter of Transmittal must be guaranteed by an eligible financial institution or broker who is a member/participant in a Medallion Program approved by the Securities Transfer Association, Inc. Please also check the appropriate box in "Special Payment Instructions" on the Election Form and Letter of Transmittal.
Special Payment Instructions. (SEE INSTRUCTIONS 1, 4, 5 AND 6) To be completed ONLY if payment is to be made by wire transfer instead of by check. Wire transfer funds to (Please Type or Print): Bank:__________________________________________ ABA Number:____________________________________ For credit to Account of:______________________ Account Number:________________________________ Ref (if any):__________________________________ EXECUTION VERSION NOTE: SIGNATURES MUST BE PROVIDED BELOW. PLEASE READ CAREFULLY THE INSTRUCTIONS BELOW FORMING PART OF THE TERMS AND CONDITIONS OF A VALID SURRENDER OF SECURITIES
Special Payment Instructions. Complete Box C only if payment is to be issued in the name of someone other than the registered holder. If you complete this box you will need a Medallion Signature Guarantee by an eligible institution (see instructions). In addition, depending on the circumstances of the payment, you may be requested to provide additional supporting documentation such as a certified copy of a trust agreement, corporate board resolutions, incumbency certificate or articles of association, as applicable. Do you want your aggregate Per Share Net Merger Consideration to be sent by electronic transfer or check? Check one
Special Payment Instructions. If the check(s) are to be made payable to or registered in a name or names other than the name(s) that appear(s) on the surrendered shares, indicate the name(s) and address in the appropriate box. The stockholder(s) named will be considered the record owner(s) and must complete the section entitled “Signatures Required” and an IRS Form W-9 (or the appropriate IRS Form W-8 if you are a non-U.S. holder, a copy of which can be obtained at xxx.xxx.xxx). If the section entitled “Special Payment Instructions” is completed, then signatures on this Election Form must be guaranteed by a firm that is a bank, broker, dealer, credit union, savings association or other entity that is a member in good standing of the Securities Transfer Agents’ Medallion Program (each, an “Eligible Institution”). If the surrendered shares are registered in the name of a person other than the person signing this Election Form, then the surrendered shares must be endorsed or accompanied by duly executed stock powers, in either case signed exactly as the name(s) of the registered owners or names that appear on such stock power(s) or with stock power(s) guaranteed by an Eligible Institution as provided herein.
Special Payment Instructions. Complete Box C only if payment is to be issued in the name of someone other than the registered holder of the Shares. If you complete this box you will need a Medallion Signature Guarantee by an eligible institution (see instructions). In addition, depending on the circumstances of the payment (e.g. payment to a party acting in a representative capacity that exceeds $5 million ($5,000,000) or payment to a high risk jurisdiction), you may be requested to provide additional supporting documentation such as a certified copy of a trust agreement, corporate board resolutions, incumbency certificate or articles of association, as applicable. Do you want the net merger consideration to be sent by electronic transfer or check? • If you select “Electronic Transfer”, complete all fields below. If you select “Check”, complete all fields below except for bank account information. IF HANDWRITING, PLEASE PRINT IN CAPITAL LETTERS. BOX D: SPECIAL DELIVERY INSTRUCTIONS Complete Box D only if payment by check in the name of the registered holder is to be sent to an address other than to the address appearing in Box A (above). If you complete this Box D, you will need a Medallion Signature Guarantee by an eligible institution (see instructions). IF HANDWRITING, PLEASE PRINT IN CAPITAL LETTERS. BOX E: AUTHORIZED SIGNATURE AND CERTIFICATION By signing below, the signer certifies that this Letter of Transmittal has not been altered in any way. If you are signing in a representative capacity such as trustee, executor, administrator, guardian, attorney-in-fact, officer of a corporation, or other capacity, under certain circumstances e.g. payment exceeding $25 million ($25,000,000) or payment to a high risk jurisdiction you may be requested to provide additional supporting documentation such as a certified copy of a trust agreement, corporate board resolution, incumbency certificate, or articles of association, as applicable. BOX F: MEDALLION SIGNATURE GUARANTEE (ONLY IF REQUIRED - PLEASE SEE INSTRUCTIONS) Exhibit 1 Form of Affidavit of Loss LOST CERTIFICATE AFFIDAVIT AND INDEMNITY AGREEMENT This Lost Certificate Affidavit and Indemnity Agreement (“Affidavit”) is made and entered into by the undersigned (the “Affiant/Stockholder”) on behalf of the Stockholder (as defined below) in favor of BeneVir Biopharm, Inc. (the “Company”), and JPMorgan Chase Bank, N.A. (the “Paying Agent”). In order to induce the Paying Agent to pay the Merger Consideration [(as defined in the Paying Agent A...
