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SECTION 302 CERTIFICATION OF TREATMENT OF MERGER PAYMENT
THE "TARGET")
(THE "ACQUIRER")
Outstanding number of shares of Acquirer common stock after merger:
(W)
Outstanding shares of Acquirer common stock after merger if all Target shareholders exchanged their Target common stock solely for Acquirer
common stock:
(X)
Please refer to the attached instructions
PLEASE COMPLETE THIS FORM IMMEDIATELY. BENEFICIAL OWNERS WHO FAIL TO COMPLETE THIS FORM BY THE APPLICABLE DEADLINE WILL
GENERALLY BE SUBJECT TO U.S. WITHHOLDING TAX AT A 30% RATE (OR LOWER RATE UNDER AN APPLICABLE TAX TREATY).
Identification of Beneficial Owner
Name of Beneficial Owner:
(Individual or Organization that is beneficial owner of the Merger Payment and was beneficial owner of the shares of Target with respect to which the Merger
Payment was made)
Account Number of Beneficial Owner:
Treatment of Merger Payment - Check Applicable Box and Provide Other Information (if required below)
CHECK ONLY ONE PART (EITHER A, B or C)
Part A
Complete Termination of Interest
Beneficial Owner's portion of the Merger Payment should be treated as a payment in exchange for Beneficial Owner's shares of Target
because Beneficial Owner (i) exchanged its shares of Target stock solely for the Merger Payment; and (ii) owned no Acquirer stock
immediately after the Merger. The Beneficial Owner owned shares of the Target immediately prior to the Merger.
Part B Meaningful Reduction in Potential Proportionate Interest -- Qualifying for Sale or Exchange Treatment
Beneficial Owner's portion of the Merger Payment should be treated as a payment in exchange for the Beneficial Owner's shares because
the Beneficial Owner's potential proportionate interest in the Acquirer has been meaningfully reduced (but not completely terminated) as
a result of the payment, as reflected in the following calculations:
Immediately after the Merger, Beneficial Owner owned _ (Y) shares of the Acquirer. The beneficial owner's
percentage ownership in Acquirer (based on the number of shares outstanding immediately after completion of the
Merger) was
(100*Y/W) %.
STEP 2: Potential Interest:
If all Target shareholders had exchanged their shares of Target common stock solely for shares of Acquirer common stock
in the Merger, Beneficial Owner would have owned
(Z) shares of Acquirer common stock immediately after
the Merger, which would represent
__
_
% (100*Z/X) of Acquirer's outstanding common stock after the Merger.
Part C Dividend
Beneficial Owner's portion of the Merger Payment should be treated for U.S. federal income tax purposes as a dividend.
*Please note, only Beneficial Owners that are properly documented for U.S. tax withholding purposes are entitled make the certification to allow the payment
to be treated as proceeds from the sale or exchange of the client's shares or to reduced treaty rates if payment is treated as dividends. Dividend payments
made to undocumented customers will be subject to 30% withholding.
CERTIFICATION
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and
complete. I further certify under penalties of perjury that I am the Beneficial Owner (or authorized to sign for the Beneficial Owner) of the Merger Payment to
which this certification relates and was the Beneficial Owner (or authorized to sign for the Beneficial Owner) of the shares of Target stock with respect to which
such portion of the Merger Payment was made.
Signature of Beneficial Owner Date (MM-DD-YYYY) Capacity in which acting
(see instructions)
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signature
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