Ill. Admin. Code tit. 50, pt. 203, exh. B

Current through Register Vol. 48, No. 49, December 6, 2024

Exhibit B - Information to be Included in Statements Filed By or on Behalf of a Participant (Other than the Company in a Proxy Solicitation in an Election Contest)

Item 1. Company. State the name and address of the company.

Item 2. Identity and Background.

a) State the following:

1) Your name and business address; and

2) Your present principal occupation or employment and the name, principal business and address of any corporation or other organization by which you are employed.

b) State the following:

1) Your residence address, age, birthplace, birthdate, and social security number; and

2) Information as to all material occupations, positions, offices or employments during the last 10 years, giving starting and ending dates of each and the name, principal business and address of any business corporation or other business organization for which each occupation, position, office or employment was carried on.

c) State whether or not you are or have been a participant in any other proxy contest involving this company or other companies within the past 10 years. If so, identify the principals, the subject matter and your relationship to the parties and the outcome.

d) State whether or not, during the past 10 years, you have been convicted in a criminal proceeding (excluding traffic violations or similar misdemeanors) and, if so, give dates, nature of conviction, name and location of court, and penalty imposed or other disposition of the case. A negative answer to this sub-item need not be included in the proxy statement or other proxy soliciting material.

Item 3. Interest in Securities of the Company.

a) State the amount of each class of securities of the company which you own beneficially, directly or indirectly.

b) State the amount of each class of securities of the company which you own of record but not beneficially.

c) State with respect to all securities of the company purchased or sold within the past 2 years, the dates on which they were purchased or sold and the amount purchased or sold on each date.

d) If any part of the purchase price or market value of any of the securities specified in paragraph (c) is represented by funds borrowed or otherwise obtained for the purpose of acquiring or holding those securities, so state and indicate the amount of the indebtedness as of the latest practical date. If the funds were borrowed or obtained other than pursuant to a margin account or bank loan in the regular course of business of a bank, broker or dealer, describe the transaction, and state the names of the parties.

e) State whether or not you are a party to any contract, arrangements or understandings with any persons concerning any securities of the company, including but not limited to joint ventures, loan or option arrangements, puts or calls, guarantees against losses or guarantees of profits, division of losses or profits, or the giving or withholding of proxies. If so, name any persons with whom such contracts, arrangements, or understandings exist and give the details thereof.

f) State the amount of securities of the company owned beneficially, directly or indirectly, by each of your associates and the name and address of each of those associates.

g) State the amount of each class of securities of any parent, subsidiary or affiliate of the company which you own beneficially, directly or indirectly.

Item 4. Further Matters.

a) Describe the time and circumstances under which you became a participant in the solicitation and state the nature and extent of your activities or proposed activities as a participant.

b) Describe briefly, and where practical state the approximate amount of any material interest, direct or indirect, of yourself and of each of your associates in any material transactions since the beginning of the company's last fiscal year, or in any material proposed transactions, to which the company or any of its subsidiaries or affiliates was or is to be a party.

c) State whether or not you or any of your associates have any arrangement or understanding with any person:

1) with respect to any future employment by the company or its subsidiaries or affiliates; or

2) with respect to any future transactions to which the company or any of its subsidiaries or affiliates will or may be a party.

If so, describe that arrangement or understanding and state the names of the parties thereto.

Item 5. Signature.

The statement must be dated and signed in the following manner:

I certify that the statements made in this statement are true, complete, and correct, to the best of my knowledge and belief.

_______________ _________________________________________

(Date)(Signature of Participant or Authorized Representative)

Ill. Admin. Code tit. 50, pt. 203, exh. B