Form 1096 Template

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Form 1096 Template Powered By Docstoc
					                                       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.

I you can use a template form, one is available in the User Documents section of
http://www.dtcc.com/products/asset/services/proxy.php


                     You may submit completed forms via email to
                           demandanddissent@dtcc.com

                                          or
                                     Postal mail to
                                      55 Water St.
                                  New York, NY 10041
                            Attn Proxy Demand and Dissent,

                                            or
                        Via fax to any of the following numbers:
                                     212-855-5181
                                     212-855-5182
                                     212-855-5183
                                     813-470-1096

         For questions or additional forms, send requests via electronic mail to:
                             demandanddissent@dtcc.com




                       737b1b7f-7fc8-4235-a5f5-0e31d7c75313.doc
                          Please submit forms to demandanddissent@dtcc.com
                    APPRAISAL RIGHTS OR DISSENTERS’ RIGHTS
                       WITHDRAWAL INSTRUCTION LETTER



                                                         Date: ______________________________


The Depository Trust Company
55 Water Street – 50th 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 withdraw the assertion
of appraisal rights with respect to ____________ shares of the above-referenced securities.
                                    (insert number)
A copy of the letter asserting appraisal rights is included as Attachment A.

Please make the letter available for pick-up by [insert name of firm or person responsible for
picking up documents from DTC] or Federal Express to ________________________________.
                                                                (name and address of contact at Participant)

The Federal Express account number is _____________________________________________.

                                                         Very truly yours,

                                                         [insert name of Participant]

                                                         BY: _______________________________
                                                            [manual signature of authorized person]

                                                         ____________________________________
                                                               [type signer’s name]


                                                         ____________________________________
                                                               [type signer’s title]

__________________________
      Medallion Stamp



                          737b1b7f-7fc8-4235-a5f5-0e31d7c75313.doc
                             Please submit forms to demandanddissent@dtcc.com
                                            Cede & Co.
                                 c/o The Depository Trust Company
                                          55 Water Street
                                       New York, NY 10041

                                                        Date: ______________________________


Name of Company
Address of Company
Contact person, name and title

Attention: ________________________________


By letter dated ______________________________, a copy of which is attached hereto as
                             (date)

Attachment A, in accordance with instructions received from_____________________________
                                                                          (name of Participant)

(“Participant”) on behalf of its customer, ____________________________________________,
                                                                 (name of customer)

we asserted appraisal rights with respect to __________________________________________.
                                                        (amount of shares and name of issue)

In accordance with instructions received from Participants on behalf of its customer, we hereby

withdraw the assertion of appraisal rights (completely) or in the amount of _________________.

Further correspondence on this matter should be directed to _____________________________,
                                                                          (name of customer)
with copies directed to the attention of ______________________________________________.
                                               (name, address and telephone of contact at Participant)

                                                        Very truly yours,


                                                        Cede & Co.


                                                        BY: _______________________________
                                                                          Partner

Attachment




                         737b1b7f-7fc8-4235-a5f5-0e31d7c75313.doc
                            Please submit forms to demandanddissent@dtcc.com

				
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Description: Form 1096 Template document sample