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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: Page 1 of 2 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: firstname.lastname@example.org Print Form Page 2 of 2 ADR COMPANY-RELATED ACTION NOTIFICATION FORM REV. (11/10) American LegalNet, Inc. www.FormsWorkFlow.com