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UNITED
STATES
SECURITIES
AND EXCHANGE COMMISSION
Washington,
D.C. 20549
FORM
8-K
CURRENT
REPORT
Pursuant
to Section 13 or 15(d) of the Securities Exchange Act of 1934
Date
of report (Date of earliest event reported): December 17, 2024
RAND
CAPITAL CORPORATION
(Exact
Name of Registrant as Specified in Its Charter)
New
York |
|
814-00235 |
|
16-0961359 |
(State
or Other Jurisdiction
of
Incorporation) |
|
(Commission
File
Number) |
|
(I.R.S.
Employer
Identification
Number) |
1405
Rand Building, Buffalo, NY 14203
(Address
of Principal Executive Offices) (Zip Code)
(716)
853-0802
(Registrant’s
Telephone Number, Including Area Code)
Not
Applicable
(Former
Name or Former Address, if Changed Since Last Report)
Check
the appropriate box below if the Form 8-K filing is intended to simultaneously satisfy the filing obligation of the registrant under
any of the following provisions:
|
☐ |
Written
communications pursuant to Rule 425 under the Securities Act (17 CFR 230.425) |
|
|
|
|
☐ |
Soliciting
material pursuant to Rule 14a-12 under the Exchange Act (17 CFR 240.14a-12) |
|
|
|
|
☐ |
Pre-commencement
communications pursuant to Rule 14d-2(b) under the Exchange Act (17 CFR 240.14d-2(b)) |
|
|
|
|
☐ |
Pre-commencement
communications pursuant to Rule 13e-4(c) under the Exchange Act (17 CFR 240.13e-4(c)) |
Securities
registered pursuant to Section 12(b) of the Act:
Title
of each class |
|
Trading
Symbol(s) |
|
Name
of each exchange on which registered |
Common
Stock, $0.10 par value |
|
RAND |
|
Nasdaq
Capital Market |
Indicate
by check mark whether the registrant is an emerging growth company as defined in Rule 405 of the Securities Act of 1933 (17 CFR §230.405)
or Rule 12b-2 of the Securities Exchange Act of 1934 (17 CFR §240.12b-2).
Emerging
growth company ☐
If
an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying
with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ☐
Item
7.01. Regulation FD Disclosure.
On
December 17, 2024, Rand Capital Corporation (the “Company”) began to send to its shareholders of record as of December 16,
2024 a notice regarding the election to be made by its shareholders in connection with the dividend announced by the Company on December
5, 2024 and payable by the Company on January 24, 2025 (the “Shareholder Notice”), along with the accompanying dividend election
form (the “Election Form”), copies of which are attached hereto as Exhibits 99.1 and 99.2, respectively.
The
information contained in this Current Report on Form 8-K, including the Shareholder Notice and Election Form, shall not be deemed “filed”
for purposes of Section 18 of the Securities Exchange Act of 1934, as amended, or otherwise subject to the liabilities of that Section,
and shall not be incorporated by reference into any registration statement pursuant to the Securities Act of 1933, as amended.
Item
9.01. Financial Statements and Exhibits.
(d)
Exhibits
SIGNATURES
Pursuant
to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by
the undersigned hereunto duly authorized.
|
RAND
CAPITAL CORPORATION |
|
|
|
Date:
December 17, 2024 |
|
|
|
|
|
|
By:
|
/s/
Daniel Penberthy |
|
Name: |
Daniel
Penberthy |
|
Title: |
Chief
Executive Officer |
Exhibit 99.1
|
IMPORTANT
INFORMATION REGARDING CASH OR STOCK ELECTION IN CONNECTION WITH RAND CAPITAL CORPORATION’s
(Nasdaq: RAND) DIVIDEND PAYABLE ON JANUARY 24, 2025
Shareholders
can elect to receive cash or stock for Rand Capital Corporation’s Q4 2024 Dividend |
December
17, 2024
On
December 5, 2024, the Board of Directors of Rand Capital Corporation (“Rand”) declared a dividend of $4.20 per share (the
“Dividend”), which represents an aggregate dividend to shareholders of approximately $10.8 million. The Dividend will be
paid in the aggregate combination of 20% in cash and 80% in newly issued shares of our common stock on or about January 24, 2025 to shareholders
of record as of December 16, 2024.
Each
shareholder will have the right to elect to receive the Dividend in cash or shares of our common stock by completing and returning the
Election Form included with this notice. Only 20% of the total Dividend paid to all shareholders will be paid in cash. If after the shareholders
have completed their elections, the total portion of the Dividend to be paid to shareholders electing to receive cash exceeds 20% of
the total Dividend, each such shareholder electing to receive cash will receive a pro-ratable portion of the total cash to be distributed
and the remaining portion of the Dividend payable to such shareholders will be paid in our common stock.
Certain
Treasury regulations and Internal Revenue Service (the “IRS”) guidance provide that dividends paid by an entity that is treated
as a publicly offered regulated investment company for U.S. federal income tax purposes, such as us, that are payable in cash or in stock
at the election of a shareholder are taxable to the shareholder regardless of whether the dividend is paid in cash, stock or a combination
of both. Based on this guidance, for U.S. federal income tax purposes, the Dividend will generally be reported by us to the IRS as a
distribution taxable as a dividend, subject to certain amounts that may be reported as exempt from tax to the extent paid to a non-U.S.
shareholder as discussed below.
The
number of shares of our common stock to be issued to shareholders receiving all or a portion of the Dividend in shares of our common
stock will be based on the volume-weighted average price per share of our common stock on the Nasdaq Capital Market on December 11, 12
and 13, 2024, which was $22.301. As such, approximately 388,806 shares of common stock are expected to be issued by Rand pursuant
to the Dividend.
Enclosed
is an election form that you must complete and deliver to Continental Stock Transfer & Trust Company by 5:00 p.m., Eastern
Time, on January 7, 2025 (the “Election Deadline”).
Election
forms must be delivered on or before the Election Deadline to be effective. Shareholders who do not return a timely and properly completed
election form before the Election Deadline will be deemed to have made an election to receive all of the Dividend in cash, subject to
proration if the total amount of cash elected by all shareholders exceeds 20% of the total Dividend.
THE
ELECTION
You
may elect to receive the Dividend in the form of cash or shares of common stock by choosing one of the election options on the accompanying
Election Form, subject to the 20% limit on cash distributions described elsewhere in this notice:
| ● | Cash
Election. You elect to receive payment of all of the Dividend in cash. |
| ● | Stock
Election. You elect to receive payment of all of the Dividend in the form of shares of
our common stock. |
1
Source: FactSet
Rand Capital Dividend Election Option |
December 17, 2024
Your
election may be limited by the cash limit described elsewhere in this notice, and you may not receive all cash to the extent these limits
require that a different allocation be made to you. We will pay cash in lieu of issuing any fractional shares of our common stock in
connection with the Dividend.
For
any given share of our common stock, an election with respect to the Dividend may be made only by the holder of record of that share
as of the close of business on December 16, 2024, which is the record date for the Dividend.
To
elect payment in cash or shares of common stock, you must complete and sign the enclosed Election Form and deliver it to Continental
Stock Transfer & Trust Company, the transfer agent, at the address below, no later than the Election Deadline. At any time before
the Election Deadline, you may change your election by timely delivery to the transfer agent of a properly completed and later-dated
Election Form.
If
you hold shares of Rand’s common stock through a bank, broker or nominee, please contact this bank, broker, or other nominee and
inform it of the election that it should make on your behalf. If you do not (or your bank, broker, or other nominee does not on your
behalf) timely return a properly completed Election Form by the Election Deadline, you will have been deemed to have made an election
to receive your Dividend in cash, subject to proration if the total amount of cash elected by all shareholders exceeds 20% of the total
Dividend.
The
method of delivery of the Election Form to Continental Stock Transfer & Trust Company, the transfer agent, is at your option and
risk, and the delivery will be deemed made only when actually received by the transfer agent. In all cases, sufficient time should be
allowed to ensure timely delivery. The submission of an Election Form with respect to the Dividend will constitute your representation
and warranty that you have full power and authority to make such election.
All
questions as to the validity, form, eligibility (including time of receipt) and acceptance by us of the Election Form will be resolved
by us, in our sole discretion and our determination as to the resolution of any such questions shall be final and binding on all parties.
We reserve the absolute right to reject, in our sole discretion, any and all Election Forms determined by us not to be in proper form,
not timely received, ineligible or otherwise invalid or the acceptance of which may, in the opinion of our counsel, be unlawful. We also
reserve the absolute right to waive any defect or irregularity in the Election Form submitted by any particular shareholder, whether
or not similar defects or irregularities are waived in the case of other shareholders. No valid election will be deemed to have been
made until all defects and irregularities have been cured or waived to our satisfaction. Neither we, nor the transfer agent, nor any
other person will be under any duty to give notification of any defects or irregularities in any Election Form or incur any liability
for failure to give any such notification. Our interpretation of the terms and conditions of the Dividend will be final and binding.
All
shares of common stock issued as part of the Dividend will be issued only in book-entry form for registered shareholders. As soon as
administratively possible after the payment date for the Dividend, the transfer agent will issue and mail to each of our shareholders
of record that is a recipient of shares of our common stock in the Dividend a statement listing the number of shares of our common stock
credited to such shareholder’s book-entry account and a payment check or direct deposit for any cash to which such shareholder
is entitled.
For
each of those shareholders who holds through a bank, broker, or other nominee, the shares of our common stock and cash to which such
shareholder is entitled will be delivered by the transfer agent through The Depository Trust Company to such shareholder’s bank,
broker, or other nominee. The bank, broker or other nominee will then allocate the shares and cash into such shareholder’s individual
account.
Rand Capital Dividend Election Option |
December 17, 2024
Completed
Election Forms must be delivered to our transfer agent, Continental Stock Transfer & Trust Company, no later than 5:00 p.m., Eastern
Time, on January 7, 2025, in the enclosed envelope in accordance with the following delivery instructions:
By
Regular Mail, Overnight Courier or Hand Delivery:
Continental
Stock Transfer & Trust Company
ATTN: HENRY FARRELL
1 State Street, 30th Floor
New
York, N.Y. 10004
If
you are a shareholder of record and need additional information about completing the attached Election Form or other matters relating
to the Dividend, please contact Continental Stock Transfer & Trust Company by phone at 212.509.4000, or by email at cstmail@continentalstock.com,
or online at https://www.continentalstock.com/contact/.
EFFECT
OF CASH LIMIT
The
total amount of cash payable for the Dividend is limited to 20% of the aggregate amount of the total Dividend, not including any cash
payments in lieu of fractional shares. If a sufficient number of shareholders elect to receive their Dividend in the form of common stock,
all shareholders who elect cash will receive their entire Dividend in cash in accordance with their election.
However,
if satisfying all shareholder elections would result in the payment of cash in excess of the 20% cash limit, then the total amount of
cash will be allocated on a pro rata basis among those shareholders who elected to receive cash. As a result, if you elect to receive
the Dividend in the form of cash, you likely will not receive the entire Dividend in the form of cash. Instead, you will receive a portion
of the Dividend to which you are entitled in cash and the remainder of the Dividend in excess of a shareholder’s pro rata share
of the total amount of cash to be distributed in the Dividend will be paid in the form of shares of our common stock (subject to the
payment of cash in lieu of any fractional shares). If you elect to receive cash, in no event will you receive less than 20% of your aggregate
Dividend in cash.
All
cash payments to which a shareholder may be entitled will be rounded to the nearest penny. The number of shares of our common stock to
be issued to shareholders receiving all or a portion of the Dividend in shares of our common stock will be based on the volume-weighted
average price per share of our common stock on the Nasdaq Capital Market on December 11, 12 and 13, 2024.
U.S.
FEDERAL INCOME TAXATION CONSIDERATIONS
The
following summary of U.S. federal income tax considerations regarding the Dividend is based on current law and is for general information
only and is not tax advice. This discussion does not purport to deal with all aspects of taxation that may be relevant to particular
holders of our common stock in light of their personal investment or tax circumstances.
U.S.
Federal Income Tax Consequences of the Dividend
For
purposes of the following discussion, a U.S. shareholder is a beneficial owner of our common stock who, for U.S. federal income tax purposes,
is:
| ● | a
citizen or resident of the United States; |
Rand Capital Dividend Election Option |
December 17, 2024
| ● | a
corporation or other entity taxable as a corporation created or organized in or under the
laws of the United States or of any state or under the laws of the District of Columbia; |
| ● | an
estate, the income of which is subject to U.S. federal income taxation regardless of its
source; or |
| ● | a
trust (a) whose administration is under the primary supervision of a U.S. court and with
respect to which one or more U.S. persons have the authority to control all substantial decisions
of the trust or (b) that has in force a valid election (under applicable Treasury Regulations)
to be treated as a U.S. person. |
A
“non-U.S. shareholder” is a beneficial owner of our common stock who is neither a U.S. shareholder nor a partnership for
U.S. federal income tax purposes (including an entity or arrangement treated as a partnership for U.S. federal income tax purposes).
If
a partnership (including an entity or arrangement treated as a partnership for U.S. federal income tax purposes) holds our common stock,
the U.S. federal income tax treatment of a partner of the partnership generally will depend upon the status of the partner, the activities
of the partnership and certain determinations made at the partner level. Partnerships holding our common stock, and persons holding interests
in such partnerships, should each consult their own tax advisors.
The
tax consequences of the Dividend will depend on a shareholder’s particular tax circumstances. Holders of our common stock are urged
to consult their tax advisors regarding the specific federal, state, local, and non-U.S. income and other tax consequences of the Dividend.
Taxation
of United States Shareholders
Distributions
we pay to U.S. shareholders from our ordinary income or from an excess of net short-term capital gain over net long-term capital loss
(together referred to hereinafter as “ordinary income dividends”) are generally taxable to shareholders as ordinary income
to the extent of our earnings and profits. Provided that certain holding period and other requirements are met, such distributions (if
properly reported by us) may qualify (i) for the dividends received deduction available to corporations, but only to the extent that
our income consists of dividend income from U.S. corporations and (ii) in the case of individual shareholders, as qualified dividend
income eligible to be taxed at long-term capital gain rates to the extent that we receive qualified dividend income (generally, dividend
income from taxable domestic corporations and certain qualified foreign corporations).
Distributions
made to a U.S. shareholder from an excess of net long-term capital gain over net short-term capital loss (“capital gain dividends”),
are taxable as long-term capital gain if they have been properly reported by us, regardless of the length of time the shareholder has
owned our common stock. Generally, following the end of each taxable year, shareholders will be provided with a written notice of the
amount of any ordinary income dividends and capital gain dividends or other distributions. Distributions in excess of our earnings and
profits will first reduce the adjusted tax basis of the shareholder’s shares and, after the adjusted tax basis is reduced to zero,
will constitute capital gain to the shareholder (assuming the shares are held as a capital asset).
Each
U.S. shareholder will receive a blank IRS Form W-9 along with this notice. All U.S. shareholders should provide a completed copy of IRS
Form W-9 when submitting the Election Form. Failure to provide a completed copy of the IRS Form W-9 may result in backup withholding
with respect to the Dividend at a rate of 24%. A U.S. shareholder will be subject to backup withholding if such U.S. shareholder is not
otherwise exempt and such U.S. shareholder:
| ● | fails
to furnish the U.S. shareholder’s taxpayer identification number (“TIN”),
which, for an individual, ordinarily is his or her social security number; |
| ● | furnishes
an incorrect TIN; |
Rand Capital Dividend Election Option |
December 17, 2024
| ● | is
notified by the IRS that the U.S. shareholder has failed properly to report payments of interest
or dividends; or |
| ● | fails
to certify, under penalties of perjury, on an IRS Form W-9 (Request for Taxpayer Identification
Number and Certification) or a suitable substitute form (or other applicable certificate),
that the U.S. shareholder has furnished a correct TIN and that the IRS has not notified the
U.S. shareholder that the U.S. shareholder is subject to backup withholding. |
U.S.
shareholders should consult their tax advisors regarding their qualification for an exemption from backup withholding and the procedures
for obtaining such an exemption, if applicable. Backup withholding is not an additional tax, and taxpayers may use amounts withheld as
a credit against their U.S. federal income tax liability or may claim a refund if they timely provide certain information to the IRS.
Taxation
of Non-United States Shareholders
In
general, distributions of our “investment company taxable income” to non-U.S. shareholders generally are subject to withholding
of U.S. federal tax at a 30% rate (or lower rate provided by an applicable treaty) to the extent of our current or accumulated earnings
and profits unless an applicable exception applies. However, no withholding will be required with respect to such distributions if (i)
the distributions are properly reported to shareholders as “interest-related dividends” or “short-term capital gain
dividends,” (ii) the distributions are derived from sources specified in the Internal Revenue Code of 1986, as amended (the “Code”)
for such dividends and (iii) certain other requirements are satisfied. No assurance can be provided that any of our distributions will
qualify for this exemption. If such distributions are effectively connected with the conduct of a trade or business in the United Stated
(a “U.S. trade or business”) by the non-U.S. shareholder (and, if a treaty applies, are attributable to a permanent establishment
maintained in the United States by the non-U.S. shareholder), we will not be required to withhold U.S. federal tax if the non-U.S. shareholder
complies with applicable certification and disclosure requirements, although the distributions will be subject to U.S. federal income
tax at the rates applicable to U.S. persons. Special certification requirements apply to a non-U.S. shareholder that is a foreign partnership
or a foreign trust, and such entities are urged to consult their own tax advisers.
Distributions
of our net capital gains to a non-U.S. shareholder if properly reported by us as capital gain dividends will not be subject to U.S. federal
income tax unless the distributions are effectively connected with a U.S. trade or business of the non-U.S. shareholder (and, if an income
tax treaty applies, are attributable to a permanent establishment maintained by the non-U.S. shareholder in the United States) or, in
the case of an individual, the non-U.S. shareholder was present in the United States for 183 days or more during the taxable year and
certain other conditions are met.
The
amount of distributions that the we pay to any non-U.S. shareholder will be reported to the non-U.S. shareholder and to the IRS annually
on an IRS Form 1042-S, regardless of whether any tax was actually withheld. Copies of these information returns may also be made available
under the provisions of a specific income tax treaty or agreement to the tax authorities of the country in which the non-U.S. shareholder
resides. However, a non-U.S. shareholder generally will not be subject to backup withholding and certain other information reporting
with respect to the Dividend, provided that we do not have actual knowledge or reason to know that such non-U.S. shareholder is a “United
States person,” within the meaning of the Code, and the non-U.S. shareholder has established that it is a non-U.S. shareholder
or otherwise established an exemption from backup withholding. A non-U.S. shareholder generally will be entitled to credit any amounts
withheld under the backup withholding rules against the non-U.S. shareholder’s U.S. federal income tax liability or may claim a
refund provided that the required information is furnished to the IRS in a timely manner. Enclosed with this notice for each non-U.S.
shareholder is a copy of a blank IRS Form W-8BEN and Form W-8BEN-E. Each non-U.S. shareholder should provide a completed copy of the
appropriate Form W-8BEN, W-8BEN-E, or other appropriate Form W-8 when submitting the Election Form.
Rand Capital Dividend Election Option |
December 17, 2024
Legislation
commonly referred to as the “Foreign Account Tax Compliance Act” of the “FATCA,” generally imposes a 30% withholding
tax on payments of certain types of income to foreign financial institutions (“FFIs”) unless such FFIs either (i) enter into
an agreement with the U.S. Treasury to report certain required information with respect to accounts held by certain specified U.S. persons
(or held by foreign entities that have certain specified U.S. persons as substantial owners) or (ii) reside in a jurisdiction that has
entered into an intergovernmental agreement (“IGA”) with the United States to collect and share such information and are
in compliance with the terms of such IGA and any enabling legislation or regulations. The types of income subject to the tax include
U.S. source interest and dividends. While the Code would also require withholding on payments of the gross proceeds from the sale of
any property that could produce U.S. source interest or dividends, the U.S. Treasury Department has indicated its intent to eliminate
this requirement in subsequent proposed regulations, which state that taxpayers may rely on the proposed regulations until final regulations
are issued. The information required to be reported includes the identity and taxpayer identification number of each account holder that
is a specified U.S. person and financial information associated with the holder’s account. In addition, subject to certain exceptions,
this legislation also imposes a 30% withholding on certain payments to certain foreign entities that are not FFIs unless the foreign
entity certifies that it does not have a greater than 10% owner that is a specified U.S. person or provides the withholding agent with
identifying information on each greater than 10% owner that is a specified U.S. person. Depending on the status of a beneficial owner
and the status of the intermediary through which it holds our common stock, a beneficial owner could be subject to this 30% withholding
tax with respect to dividends with respect to our common stock. Under certain circumstances, a non-U.S. shareholder might be eligible
for refunds or credit of such taxes.
Non-U.S.
shareholders should consult their own tax advisors with respect to the U.S. federal income tax and withholding tax consequences of the
Dividend in light of their own unique circumstances.
This
summary is general in nature and was not intended or written to be used, and it cannot be used by any taxpayer, for the purpose of avoiding
penalties that may be imposed on the taxpayer. Each shareholder should seek advice based on such shareholder’s particular circumstances
from an independent tax advisor.
Where
You Can Find More Information
We
file annual, quarterly and current reports, proxy statements and other information with the U.S. Securities and Exchange Commission (the
“SEC”). The SEC maintains a website that contains reports, proxy and information statements, and other information regarding
issuers that file electronically with the SEC, including us, that is available over at http://www.sec.gov. This information is
also available on our website at www.randcapital.com.
Exhibit
99.2
RAND
CAPITAL CORPORATION
DIVIDEND
ELECTION FORM
You
may elect to receive the Dividend, payable on January 24, 2025, in the form of cash or shares of common stock of Rand Capital Corporation
by returning this Dividend Election Form. Prior to making an election, please read carefully and in its entirety the accompanying notice
from Rand Capital Corporation, dated December 17, 2024, as all elections are subject to the terms of the Dividend as described in the
accompanying notice. Your election must be made by returning this Dividend Election Form to Continental Stock Transfer & Trust
Company by 5:00 P.M. Eastern Time on January 7, 2025. If you do not timely and properly make an election, you will be deemed not
to have made an election.
The
actual proportion of shares or cash you receive in the Dividend may be different than what you elect on this Dividend Election Form.
Your Dividend distribution will be dependent upon the pro-rata allocation that results from the combined elections of all shareholders
and is subject to the 20% cash limitation on the Dividend (each as described in greater detail in the accompanying notice).
Please
complete, sign, and date this Dividend Election Form in blue or black ink, by making a check mark or “X” in one of the boxes
provided below and return it in the enclosed self-addressed envelope to Continental Stock Transfer & Trust Company, 1 State Street,
30th Floor, New York, N.Y. 10004, ATTN: HENRY FARRELL.
You
may check ONLY one election. The number of shares of common stock of Rand Capital Corporation that are held in your account
as of the close of business on December 16, 2024, the record date for the Dividend, is indicated below.
THIS
DIVIDEND ELECTION FORM IS VALID ONLY WHEN COMPLETED, SIGNED, DATED AND RETURNED TO CONTINENTAL STOCK TRANSFER & TRUST COMPANY BY
5:00 P.M. EASTERN TIME ON JANUARY 7, 2025.
DIVIDEND
ELECTION FORM
RAND
CAPITAL CORPORATION
Option
1 |
|
Option
2 |
|
|
|
☐
CASH ELECTION: I ELECT TO RECEIVE THE DIVIDEND ALL IN CASH, SUBJECT TO PRORATION IF THE TOTAL AMOUNT OF CASH ELECTED BY SHAREHOLDERS
EXCCEEDS THE 20% CASH LIMITATION |
|
☐
STOCK ELECTION: I ELECT TO RECEIVE THE DIVIDEND ALL IN SHARES OF RAND CAPITAL COMMON STOCK (INCLUDING CASH IN LIEU OF FRACTIONAL
SHARES OF COMMON STOCK) |
|
|
|
ACCOUNT
NUMBER: |
|
NUMBER
OF SHARES HELD: |
THIS
DIVIDEND ELECTION FORM IS VALID ONLY WHEN COMPLETED, SIGNED, DATED AND RETURNED TO CONTINENTAL STOCK TRANSFER & TRUST COMPANY BY
5:00 P.M. EASTERN TIME ON JANUARY 7, 2025.
IF
YOU DO NOT TIMELY RETURN A PROPERLY COMPLETED ELECTION FORM YOU WILL BE DEEMED TO HAVE ELECTED TO RECEIVE THE DIVIDEND ALL IN CASH (SUBJECT
TO PRORATION IF THE TOTAL AMOUNT OF CASH ELECTED BY SHAREHOLDERS EXCEEDS THE 20% CASH LIMITATION)
Signature:
__________________________ Co-Owner Signature:___________________________________
Date:
________________, 202_
Note:
Please sign exactly as name(s) appear(s) hereon. Joint owners should each sign. When signing as an attorney, executor, administrator,
corporate officer, trustee, guardian, or custodian, please state your title.
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