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ADR Company-Related Action Notification Form. This is a Official Federal Forms form and can be use in FINRA.
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ADR Company-Related Action Notification Form
Completion of this form certifies to FINRA notification of a Company-Related Action request for the ADR by the Depositary in compliance with FINRA Rule
6490 and SEA Rule 10b-17. All notifications are required to be received by FINRA no later than 10 calendar days prior to the effective date of the corporate
action. Processing for the effective time in the market place is determined based upon the satisfactory review of and compliance with all information
requested by FINRA.
Depositary Information
Depositary Name:
Contact Name:
Title:
Telephone:
Email:
Facsimile:
Security Information
Sponsored
ADR Name:
Current Issue Symbol:
Is Depositary the First Filer?
Current CUSIP:
Yes
Yes - defer to Acting
Unsponsored
Ordinary Issue Symbol:
Acting First Filer
No
Home Market Country:
Company-Related Action (Please see section entitled FINRA 6490 Fee Schedule for applicable fee)
Cash Dividend/Distribution
Stock Dividend/Distribution
Approximate Rate
Final Rate
Stock Dividend Rate:
Issuance Fee:
Ratio (Underlying Shares : DR):
:
DR Cash-in-Lieu Rate:
Record Date:
Payable Date:
Record Date:
Payable Date:
Dividend Rate:
Net Dividend Rate:
Payable Date:
Ex-Date:
Dividend Fee:
Withholding Tax:
USD:
@
%
Comments:
Underlying Shares:
Record Date:
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ADR COMPANY-RELATED ACTION NOTIFICATION FORM REV. (11/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
ADR Program Change
New ADR Name:
Is Name Change Concurrent with Split?
Yes
Payable Upon Surrender
Effective Date:
Mailed Directly to Shareholders
New Ratio:
No
New CUSIP (if applicable):
Is this Corporate Action Effective in the Ordinary Market?
Yes
Effective Date:
No
Details of Corporate Action in Ordinary Market (if applicable):
FINRA Rule 6490 Fee Schedule
SEA Rule 10b-17 Action
Fee
Timely SEA Rule 10b-17 Notification Notice Submitted at least 10 calendar days prior to corporate action date
$200
Late SEA Rule 10b-17 Notification
Notice Submitted at least 5 calendar days prior to corporate action date
$1,000
Late SEA Rule 10b-17 Notification
Notice Submitted at least 1 calendar day prior to corporate action date
$2,000
Late SEA Rule 10b-17 Notification
Notice Submitted on or after corporate action date
$5,000
Submission of Notification:
FINRA, Operations via:
Fax: (202) 689-3532, or
Email: otcdividends@finra.org
Print Form
Page 2 of 2
ADR COMPANY-RELATED ACTION NOTIFICATION FORM REV. (11/10)
American LegalNet, Inc.
www.FormsWorkFlow.com