(1) Title of each class of securities to which transaction applies: | |
(2) Aggregate number of securities to which transaction applies: | |
(3)
Per unit price or other underlying value of transaction computed pursuant
to Exchange Act Rule 0-11 (set forth the amount on which the filing
fee is calculated and state how it was determined):
|
|
(4) Proposed maximum aggregate value of transaction: | |
(5) Total fee paid: | |
(1) Amount Previously Paid: | |
(2) Form, Schedule or Registration Statement No.: | |
(3) Filing Party: | |
(4) Date Filed:
|
|
||
Sincerely, | ||
|
||
David J. Schulte | ||
Chief
Executive Officer
|
||
|
1.
|
To
elect two directors of the Company, to hold office for a term of three
years and until their successors are duly elected and
qualified;
|
|
2.
|
To
consider and vote upon a proposal to authorize flexibility to the Company
to sell its common shares for less than net asset value, subject to
certain conditions;
|
|
3.
|
To
consider and vote upon a proposal to authorize the Company to sell
warrants or securities to subscribe for or convertible into shares of
common stock and to issue the common shares underlying such warrants or
securities upon their exercise;
|
|
4.
|
To
ratify the selection of Ernst & Young LLP as the independent
registered public accounting firm of the Company for its fiscal year
ending November 30, 2009; and
|
|
5.
|
To
consider and take action upon such other business as may properly come
before the meeting including the adjournment or postponement
thereof.
|
By
Order of the Board of Directors of the Company
|
||
|
||
Connie J. Savage | ||
Secretary
|
||
Name and Age
|
Positions(s)
Held
With
The Company and Length of
Time
Served
|
Principal
Occupation
During Past Five Years
|
Number
of Portfolios in Fund Complex Overseen by Director
|
Other
Public Company
Directorships
Held
by Director
|
|
Charles
E. Heath*
(Born
1942)
|
Director
of the Company since its inception in 2005.
|
Retired
in 1999. Formerly, Chief Investment Officer, GE Capital’s
Employers Reinsurance Corporation (1989-1999); Chartered Financial Analyst
(“CFA”) designation since 1974.
|
Six
|
None
|
|
Terry
C. Matlack*
(Born
1956)
|
Director
and Chief Financial Officer of the Company since its inception; Assistant
Treasurer of the Company from its inception to April 2008.
|
Managing
Director of the Adviser since 2002; Full-time Managing Director, Kansas
City Equity Partners LC (“KCEP”), a private equity firm (2001- 2002).
Formerly, President, GreenStreet Capital (1995 - 2001); CFA designation
since 1985.
|
Six
|
None
|
Name and Age
|
Positions(s)
Held
With
The Company and Length of
Time
Served
|
Principal
Occupation
During Past Five Years
|
Number
of Portfolios in Fund Complex Overseen by Director
|
Other
Public Company
Directorships
Held
by Director
|
John
R. Graham*
(Born
1945)
|
Director
of the Company since its inception.
|
Executive-in-Residence
and Professor of Finance (Part-time), College of Business Administration,
Kansas State University (has served as a professor or adjunct professor
since 1970); Chairman of the Board, President and CEO, Graham Capital
Management, Inc. (primarily a real estate development, investment and
venture capital company) and Owner of Graham Ventures (a business services
and venture capital firm); Part-time Vice President Investments, FB
Capital Management, Inc. (a registered investment adviser), since
2007. Formerly, CEO, Kansas Farm Bureau Financial Services,
including seven affiliated insurance or financial service companies
(1979-2000).
|
Six
|
Kansas
State Bank
|
Conrad
S. Ciccotello*
(Born
1960)
|
Director
of the Company since its inception.
|
Tenured
Associate Professor of Risk Management and Insurance, Robinson College of
Business, Georgia State University (faculty member since 1999); Director
of Graduate Personal Financial Planning Programs;
formerly, Editor, Financial Services Review
(an academic journal dedicated to the study of individual financial
management) (2001-2007); formerly, faculty member, Pennsylvania State
University (1997-1999). Published several academic and professional
journal articles about energy infrastructure and oil and gas
MLPs.
|
Six
|
None
|
Name and Age
|
Positions(s)
Held
With
The Company and Length of
Time
Served
|
Principal
Occupation
During Past Five Years
|
Number
of Portfolios in Fund Complex Overseen by Director
|
Other
Public Company
Directorships
Held
by Director
|
H.
Kevin Birzer*
(Born
1945)
|
Director
and Chairman of the Board of the Company since its inception.
|
Managing
Director of the Adviser since 2002; Member, Fountain Capital Management,
L.L.C. (“Fountain Capital”), a registered investment adviser (1990 –
present). Formerly, Vice President, Corporate Finance Department, Drexel
Burnham Lambert (1986-1989); and Vice
President, F. Martin Koenig & Co. (1983- 1986).
|
Six
|
None
|
Name and
Age
|
Position(s)
Held
With
The Company and Length of
Time
Served
|
Principal
Occupation
During Past Five Years
|
Number
of Portfolios in Fund Complex Overseen by Officer
|
Other
Public Company
Directorships
Held
by Officer
|
David
J. Schulte
(Born
1961)
|
Chief
Executive Officer since inception; President from inception to April
2007.
|
Managing
Director of the Adviser since 2002; Full-time Managing Director, KCEP
(1993-2002); CFA designation since 1992.
|
Six
|
None
|
Zachary
A. Hamel
(Born
1965)
|
Senior
Vice President since inception; Secretary from inception to April
2007.
|
Managing
Director of the Adviser since 2002; Partner, Fountain Capital
(1997-present).
|
Six
|
None
|
Name and
Age
|
Position(s)
Held
With
The Company and Length of
Time
Served
|
Principal
Occupation
During Past Five Years
|
Number
of Portfolios in Fund Complex Overseen by Officer
|
Other
Public Company
Directorships
Held
by Officer
|
Kenneth
P. Malvey
(Born
1965)
|
Senior
Vice President and Treasurer since inception.
|
Managing
Director of the Adviser since 2002; Partner, Fountain Capital
(2002-present). Formerly, Investment Risk Manager and member of
the Global Office of Investments, GE Capital’s Employers Reinsurance
Corporation (1996-2002).
|
Six
|
None
|
Edward
Russell
(Born
1964)
|
President
since April 2007.
|
Senior
Investment Professional of the Adviser since 2006; formerly Managing
Director (1999-2006) in investment banking department of Stifel, Nicolaus
& Company, Incorporated, responsible for all of the energy and power
transactions, including all of the debt and equity transactions, prior to
joining the Adviser, for three of the closed-end public funds managed by
the Adviser, starting with the first public equity offering in February
2004, and the first private placement transaction for the
Company.
|
Two
|
None
|
·
|
Executive
Committee. The Company’s Executive Committee has
authority to exercise the powers of the Board (i) to address emergency
matters where assembling the full Board in a timely manner is
impracticable, or (ii) to address matters of an administrative or
ministerial nature. Messrs. Birzer and Matlack are “interested
persons” of the Company as defined by Section 2(a)(19) of the 1940
Act.
|
·
|
Audit and Valuation
Committee. The Company’s Audit and Valuation Committee
was established in accordance with Section 3(a)(58)(A) of the
Securities Exchange Act of 1934, as amended (the “Exchange Act”), and
operates under a written charter adopted and approved by the Board, a
current copy of which is available on the Company’s website (www.tortoiseadvisors.com/tto.cfm)
and in print to any stockholder who requests it from the Secretary of the
Company at 11550 Ash Street, Suite 300, Leawood, Kansas
66211. The Audit and Valuation Committee: (i) approves and
recommends to the Board the election, retention or termination of the
independent registered public accounting firm (the “independent
auditors”); (ii) approves services to be rendered by the independent
auditors and monitors the independent auditors’ performance; (iii) reviews
the results of the Company’s audit; (iv) determines whether to recommend
to the Board that the Company’s audited financial statements be included
in the Company’s Annual Report; (v) reviews the portfolio Company
valuations proposed by the Adviser’s investment committee; and (vi)
responds to other matters as outlined in the Committee’s
Charter. Each Audit and Valuation Committee member is
“independent” as defined under the New York Stock Exchange listing
standards, and none are “interested persons” of the Company as defined in
the 1940 Act. The Board of Directors has determined that Conrad S.
Ciccotello is an “audit committee financial expert.” In
addition to his experience overseeing or assessing the performance of
companies or public accountants with respect to the preparation, auditing
or evaluation of financial statements, Mr. Ciccotello has a Ph.D. in
Finance.
|
·
|
Nominating, Corporate
Governance and Compensation Committee. The Company’s
Nominating, Corporate Governance and Compensation Committee operates under
a written charter adopted and approved by the Board, a current copy of
which is available on the Company’s website (www.tortoiseadvisors.com/tto.cfm)
and in print to any stockholder who requests it from the Secretary of the
Company at 11550 Ash Street, Suite 300, Leawood, Kansas
66211. The Nominating, Corporate Governance and Compensation
Committee: (i) identifies individuals qualified to become
Board members and recommends to the Board the director nominees for the
next annual meeting of stockholders and to fill any vacancies;
(ii) monitors the structure and membership of Board committees and
recommends to the Board director nominees for each committee;
(iii) reviews issues and developments related to corporate governance
issues and develops and recommends to the Board corporate governance
guidelines and procedures; (iv) evaluates and makes recommendations
to the Board regarding director compensation; (v) oversees the
evaluation of the Board and management; (vi) has the
sole authority to
|
retain and terminate any search firm used to identify director candidates and to approve the search firm’s fees and other retention terms, though it has yet to exercise such authority; and (vii) may not delegate its authority. The Nominating, Corporate Governance and Compensation Committee will consider stockholder recommendations for nominees for membership to the Board so long as such recommendations are made in accordance with the Company’s Bylaws. Nominees recommended by stockholders in compliance with the Bylaws of the Company will be evaluated on the same basis as other nominees considered by the Nominating, Corporate Governance and Compensation Committee. Stockholders should see “Stockholder Proposals and Nominations for the 2010 Annual Meeting” below for information relating to the submission by stockholders of nominees and matters for consideration at a meeting of the Company’s stockholders. The Company’s Bylaws require all directors and nominees for directors (i) to be at least 21 years of age and have substantial expertise, experience or relationships relevant to the business of the Company, and (ii) to have a master’s degree in economics, finance, business administration or accounting, to have a graduate professional degree in law from an accredited university or college in the United States or the equivalent degree from an equivalent institution of higher learning in another country, to have a certification as a public accountant in the United States, to be deemed an “audit committee financial expert” as such term is defined in item 401 of Regulation S-K as promulgated by the SEC, or to be a current director of the Company. The Nominating, Corporate Governance and Compensation Committee has the sole discretion to determine if an individual satisfies the foregoing qualifications. Each Nominating, Corporate Governance and Compensation Committee member is “independent” as defined under the New York Stock Exchange listing standards and none are “interested persons” of the Company as defined in the 1940 Act. |
·
|
Compliance
Committee. The Company
formed this committee in April 2007. Each committee member is
“independent” as defined under the New York Stock Exchange listing
standards, and none are “interested persons” of the Company as defined in
the 1940 Act. The Company’s Compliance Committee operates under
a written charter adopted and approved by the Board. The
committee reviews and assesses management’s compliance with applicable
securities laws, rules and regulations; monitors compliance with the
Company’s Code of Ethics; and handles other matters as the Board or
committee chair deems appropriate.
|
Board
of Directors
|
6
|
Executive
Committee
|
0
|
Audit
and Valuation Committee
|
2
|
Nominating,
Corporate Governance and Compensation Committee
|
1
|
Compliance
Committee
|
1
|
Name
of Person,
Position
|
Aggregate
Compensation
from
Company (1)
|
Pension
or
Retirement
Benefits
Accrued
as
Part
of
Company
Expenses
|
Estimated
Annual Benefits Upon Retirement
|
Total
Compensation from Company
and
Fund
Complex
Paid
to Directors
(2)
|
Independent
Persons
|
||||||||
Conrad
S. Ciccotello
|
$30,000
|
$0
|
$0
|
$182,000
|
||||
John
R. Graham
|
$27,000
|
$0
|
$0
|
$171,000
|
||||
Charles
E. Heath
|
$27,000
|
$0
|
$0
|
$171,000
|
|
|
Sales
Price
|
|
High
Sales Price
to
NAV(2)
|
Low
Sales Price
to
NAV(2)
|
||||||||||
|
NAV(1)
|
|
High
|
|
Low
|
|
|||||||||
Fiscal
Year ended November 30, 2007
|
|
|
|
|
|||||||||||
First
Quarter(3)
|
|
$13.84
|
|
$15.03
|
|
$14.50
|
|
8.6
|
%
|
|
4.8
|
%
|
|||
Second
Quarter
|
|
$14.05
|
$18.47
|
|
$14.31
|
|
31.5
|
%
|
|
1.9
|
%
|
||||
Third
Quarter
|
|
$13.77
|
|
$18.99
|
|
$13.79
|
|
37.9
|
%
|
|
0.1
|
%
|
|||
Fourth
Quarter
|
|
$13.76
|
|
$15.29
|
|
$11.66
|
|
11.1
|
%
|
|
-15.3
|
%
|
|||
Fiscal
Year ended November 30, 2008
|
|
|
|
|
|
||||||||||
First
Quarter
|
|
$13.28
|
|
$13.05
|
|
$11.00
|
|
-1.7
|
%
|
|
-17.2
|
%
|
|||
Second
Quarter
|
|
$13.69
|
|
$13.42
|
|
$11.80
|
|
-2.0
|
%
|
|
-13.8
|
%
|
|||
Third
Quarter
|
|
$13.38
|
|
$12.52
|
|
$11.00
|
|
-6.4
|
%
|
|
-17.8
|
%
|
|||
Fourth
Quarter
|
|
$9.96
|
|
$11.18
|
|
$4.40
|
|
12.2
|
%
|
|
-55.8
|
%
|
(1)
|
NAV
is determined as of the last day in the relevant quarter and therefore may
not reflect the net asset value per share on the date of the high and low
sales prices. The net asset values shown are based on outstanding shares
at the end of each period.
|
(2)
|
Calculated
as the respective high or low sales price divided by NAV.
|
(3)
|
The
Company closed its initial public offering on February 7, 2007 and as such
its shares were not traded on the New York Stock Exchange during the
entire quarter.
|
|
|
Example 1
5%
Offering
at
5% Discount
|
|
Example 2
10%
Offering
at
10% Discount
|
|
Example 3
20%
Offering
at
20% Discount
|
|||||||
|
Prior
to Sale
Below
NAV
|
|
Following
Sale
|
|
%
Change
|
|
Following
Sale
|
|
%
Change
|
|
Following
Sale
|
|
%
Change
|
Offering
Price
|
|||||||||||||
Price
per Share to
Public
|
--
|
$ 10.00
|
--
|
$ 9.47
|
--
|
$ 8.42
|
--
|
||||||
Net
Proceeds per Share to
Issuer
|
--
|
$ 9.50
|
--
|
$ 9.00
|
--
|
$ 8.00
|
--
|
||||||
Decrease
to NAV
|
|||||||||||||
Total
Shares
Outstanding
|
1,000,000
|
1,050,000
|
5.00%
|
1,100,000
|
10.00%
|
1,200,000
|
20.00%
|
||||||
NAV
per
Share
|
$ 10.00
|
$ 9.98
|
(0.20)%
|
$ 9.91
|
(0.90)%
|
$ 9.67
|
(3.30)%
|
||||||
Share
Dilution to Stockholder
|
|||||||||||||
Shares
Held by Stockholder
A
|
10,000
|
10,000
|
--
|
10,000
|
--
|
10,000
|
--
|
||||||
Percentage
of Shares Held by Stockholder A
|
1.0%
|
0.95%
|
(4.76)%
|
0.91%
|
(9.09)%
|
0.83%
|
(16.67)%
|
||||||
Total Asset Values
|
|||||||||||||
Total NAV Held by Stockholder A
|
$ 100,000
|
$ 99,800
|
(0.20)%
|
$ 99,100
|
(0.90)%
|
$ 96,700
|
(3.30)%
|
||||||
Total
Investment by Stockholder A (Assumed to Be $10.00 per
Share)
|
$ 100,000
|
$ 100,000
|
--
|
$ 100,000
|
--
|
$ 100,000
|
--
|
||||||
Total
Dilution to Stockholder A (Total NAV Less Total
Investment)
|
--
|
$ (200)
|
--
|
$ (900)
|
--
|
$ (3,300)
|
--
|
||||||
Per Share Amounts
|
|||||||||||||
NAV
per Share Held by Stockholder A
|
--
|
$ 9.98
|
--
|
$ 9.91
|
--
|
$ 9.67
|
--
|
||||||
Investment
per Share Held by Stockholder A (Assumed to be $10.00 per Share on Shares
Held Prior to Sale)
|
$ 10.00
|
$ 10.00
|
--
|
$ 10.00
|
--
|
$ 10.00
|
--
|
||||||
Dilution
per Share Held by Stockholder A (NAV per Share Less Investment per
Share)
|
--
|
$ (0.02)
|
--
|
$ (0.09)
|
--
|
$ (0.33)
|
--
|
||||||
Percentage
Dilution to Stockholder A (Dilution per Share Divided by Investment per
Share)
|
--
|
--
|
(0.20)%
|
--
|
(0.90)%
|
--
|
(3.30)%
|
||||||
·
|
a
“required majority” of the Company’s directors have determined that any
such sale would be in the best interests of the Company and its
stockholders; and
|
·
|
a
“required majority” of the Company’s directors, in consultation with the
underwriter or underwriters of the offering if it is to be underwritten,
have determined in good faith, and as of a time immediately prior to the
first solicitation by or on behalf of the Company of firm
|
commitments to
purchase such common stock or immediately prior to the issuance of such common stock, that the price at which such shares
of common stock are to be sold is not less than a price which closely
approximates the market value of those shares of common stock, less any
distributing commission or
discount.
|
2008
|
2007
|
|
Audit
Fees1
|
$279,900
|
$361,300
|
Audit-Related
Fees2
|
$ -
|
$ 2,300
|
Tax
Fees3
|
$
28,500
|
$ 45,600
|
All
Other Fees
|
$ -
|
-
|
Aggregate
Non-Audit Fees
|
$
28,500
|
$ 47,900
|
1
|
For
professional services rendered auditing the Company’s annual financial
statements, reviewing interim financial statements, and reviewing the
Company’s statutory and regulatory filings with the SEC, including the
Company’s filings related to its initial public offering. The
audit fees for November 30, 2008 and November 30, 2007 are based on
amounts billed and expected to be billed by
E&Y.
|
2
|
For
professional services rendered researching the application of accounting
standards.
|
3
|
For
professional services rendered to the Company for tax compliance, tax
advice and tax planning.
|
Directors and Officers
|
Number
of
Common Shares
|
Percent
of Class(1)
|
Independent
Directors
|
||
Conrad
S. Ciccotello(2)
|
2,938.90
|
*
|
John
R. Graham(3)
|
5,671.02
|
*
|
Charles
E. Heath(4)
|
4,253.27
|
*
|
Interested
Directors and Officers
|
||
H.
Kevin Birzer(5)
|
26,428.92
|
*
|
Terry
C. Matlack(6)
|
9,467.20
|
*
|
David
J. Schulte(7)
|
13,204.04
|
*
|
Zachary
A. Hamel(8)
|
5,750.76
|
*
|
Kenneth
P. Malvey(9)
|
8,292.54
|
*
|
Edward
Russell
|
6,098.65
|
*
|
Directors
and Officers as a Group(10)
|
82,105.30
|
*
|
|
*Indicates
less than 1%.
|
|
(2)
|
Mr. Ciccotello
holds 1,010.38 of these shares jointly with his wife. Includes
250 shares of common stock that may be acquired through warrants that are
currently exercisable.
|
(3)
|
These
shares are held of record by the John R. Graham Trust U/A dtd 1/3/92, John
R. Graham, sole trustee and include warrants to purchase 1,000 shares of
common stock that may be acquired through warrants that are currently
exercisable.
|
(4)
|
These
shares are held of record by the Charles E Health Trust No. 1 dtd U/A
2/1/92, Charles E. Heath, co-trustee and include 750 shares of common
stock that may be acquired through warrants that are currently
exercisable.
|
(5)
|
Mr. Birzer
holds 25,228.92 shares and 1,325 warrants jointly with his wife and holds
1,200 shares for the benefit of his children in an account established
under the Kansas Uniform Transfer to Minor’s Act for which his wife is the
custodian. Includes 1,325 shares of common stock that may be
acquired through warrants that are currently
exercisable.
|
(6)
|
These
shares are held of record by the Matlack Living Trust dtd 12/30/2004, for
which Mr. Matlack and his wife are co-trustees and include 616 shares of
common stock that may be acquired through warrants that are currently
exercisable.
|
(7)
|
Includes
1,128 shares of common stock that may be acquired through warrants that
are currently exercisable. Mr. Schulte holds 12,083 shares and
966 warrants jointly with his wife; 200 shares are held in accounts for
spouse’s children for which she is the custodian and of which Mr. Schulte
disclaims beneficial
ownership.
|
(8)
|
Includes
416 shares of common stock that may be acquired through warrants that are
currently exercisable.
|
(9)
|
Mr.
Malvey holds 100 shares for the benefit of his child in an account for
which he is the custodian, and holds 166 warrants jointly with his wife;
1,500 shares are held by his wife. Includes 347 shares of
common stock that may be acquired through warrants that are currently
exercisable.
|
(10)
|
Includes
5,832 shares of common stock that may be acquired through warrants that
are currently exercisable.
|
Name and Address
|
Number
of
Common Shares
|
Percent of Class
|
Kenmont
Investments Management, L.P.
711 Louisiana, Suite 1750, Houston,
TX 77002(1)
|
786,832
|
8.5%
|
(1)
|
Information
with respect to Kenmont entities is based on a Schedule 13G amendment
filed on February 17, 2009. Kenmont Investments Management,
L.P. (“Kenmont”) serves as investment manager to several entities that
beneficially own the Company’s securities, each of which is more fully
described in that Schedule 13G amendment. Includes 281,666
shares of common stock that may be acquired through warrants that are
currently exercisable.
|
Director
|
Aggregate
Dollar Range of
Holdings
in the Company (1)(2)
|
Aggregate
Dollar Range of
Holdings
in Funds Overseen
by
Director in
Fund
Complex (2)(3)
|
Interested
Persons
|
||
H.
Kevin Birzer
|
Over
$100,000
|
Over
$100,000
|
Terry
C. Matlack
|
$10,001
- $50,000
|
Over
$100,000
|
Independent
Persons
|
||
Conrad
S. Ciccotello
|
$10,001-$50,000
|
Over
$100,000
|
John
R. Graham
|
$10,001-$50,000
|
Over
$100,000
|
Charles
E. Heath
|
$10,001-$50,000
|
Over
$100,000
|
(1)
|
Based
on the closing price of the Company’s common shares on the New York Stock
Exchange on December 31, 2008.
|
(2)
|
No
value included for warrants to purchase shares of the Company’s common
stock held by the directors since the exercise price of the warrants
exceeded the closing price of the Company’s common shares on the New York
Stock Exchange on December 31,
2008.
|
(3)
|
Includes
the Company, TYG, TYY, TYN, TTRF and TGOC. Amounts based on the
closing price of the common shares of the Company, TYG, TYY and TYN on the
New York Stock Exchange on December 31, 2008; the NAV of TTRF at
December 31, 2008 and the NAV of TGOC at November 30,
2008.
|
|
CERTAIN
RELATIONSHIPS AND RELATED PARTY
TRANSACTIONS
|
By
Order of the Board of Directors of the Company
|
||
|
||
Connie J. Savage | ||
Secretary
|
||
2.
|
Approval
for the Company, with the approval of its Board of Directors, to sell or
otherwise issue shares of its common stock at a price below its then
current net asset value per share subject to the limitations set forth in
the proxy statement for the 2009 annual meeting of
stockholders.
|
|
For
|
Against
|
Abstain
|
[ ] | [ ] | [ ] |
3.
|
Approval
for the Company’s sale, with approval of its Board of Directors, of
warrants or securities to subscribe for or convertible into shares of
common stock and issuance of the common shares issuable pursuant to such
warrants or securities, subject to the limitations set forth in the proxy
statement for the 2009 annual meeting of stockholders.
|
For
|
Against
|
Abstain
|
|
[ ] | [ ] | [ ] |
4.
|
Ratification
of Ernst & Young LLP as the Company’s independent registered public
accounting firm to audit the financial statements of the Company for the
fiscal year ending November 30,
2009.
|
For
|
Against
|
Abstain
|
|
[ ] | [ ] | [ ] |
5.
|
To
vote and otherwise represent the undersigned on such other matters as may
properly come before the meeting including the adjournment or postponement
thereof, if proposed.
|
Mark
box to the right
|
||||
if
you plan to attend the Annual Meeting.
|
|
Please
sign exactly as your name appears. If acting as attorney,
executor, trustee, or in representative capacity, sign name and indicate
title.
|
Date
(mm/dd/yyyy) – Please print date below
|
Signature
1 – Please keep signature within the box.
|
Signature
2 – Please keep signature within the box.
|
||
/ /
|