Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notification Form - Cash Dividend-Distribution Form. This is a Official Federal Forms form and can be use in General Forms NASDAQ.
Loading PDF...
Tags: Notification Form - Cash Dividend-Distribution, Official Federal Forms NASDAQ, General Forms
The NASDAQ Stock Market®
Notification:
Cash Dividend/Distribution
Pursuant to Listing Rule 5250(e)(6) and SEC Rule 10b-17, the issuer of any class of securities listed on
The NASDAQ Stock Market must notify NASDAQ® ten calendar days prior to the record date of a cash
dividend or other distribution in cash. The issuer must also provide public disclosure of the dividend
action using a Regulation FD compliant method. Notice to NASDAQ should be given as soon as possible
after declaration, and, in any event, no later than simultaneously with the public disclosure. Please
note that prior notification of the public disclosure must also be provided to NASDAQ MarketWatch
through the Electronic Disclosure submission system.
NASDAQ will use the information in this Notification to determine an ex-dividend date for the
distribution, which is the date on which the security will start trading without the right to receive the
dividend or distribution. The information provided in this Notification is subject to immediate
public disclosure in connection with NASDAQ’s announcement of the ex-dividend date.
Any non-cash distributions (for example, stock splits, stock dividends, spin-offs or rights offerings) should
be reported on the Notification: Non-Cash Dividend/Distribution.
PART I: General Information
COMPANY NAME
SYMBOL
TRANSFER AGENT
EMAIL
PHONE
SECURITY CLASS AND DESCRIPTION
CUSIP/CINS NUMBER
NASDAQ will provide an email confirmation of the ex-dividend date ruling with respect to this
Notification. Please indicate who the primary and secondary contact should be for correspondence on
dividend related matters.
PRIMARY CONTACT NAME
EMAIL
PHONE
SECONDARY CONTACT NAME
EMAIL
PHONE
1
American LegalNet, Inc.
www.FormsWorkFlow.com
PART II: Dividend/Distribution Information
1.
Declaration Date:
Record Date:
2.
Amount of cash per share:
_
3.
Is the distribution a “Qualified Dividend” as defined under the provisions of The Jobs and
Growth Tax Relief Reconciliation Act of 2003:
Yes
No
Not Known
4.
Dividend amount is: (Please check one.)
Monthly
Quarterly
Semi-annual
Distribution Date:
_
__
Annual
Special*
Other*
*If this dividend is classified as “special” or “other”, please explain. Also, if the dividend is a
special dividend, the company’s public disclosure should indicate this fact.
__________________________________________________
____________________________________________
____________________________________________
____________________________________________
5.
_ _
__
__
__
Explain any conditions, which must be met (for example, shareholder approval, government
approval, SEC registration, etc.) for this distribution to become effective:
__________________________________________________
____________________________________________
____________________________________________
____________________________________________
_ _
__
__
__
Authorized Signature
NAME
TITLE
SIGNATURE
DATE
Please email this Notification to dividends@nasdaqomx.com. You may also fax this
Notification to Corporate Data Operations at +1 866 601 9862 (toll free) or +1 203 926 3375.
Questions about this Notification may be directed to NASDAQ Corporate Data Operations at
dividends@nasdaqomx.com or +1 877 308 0523 (toll free) or +1 203 926 3501.
Note: Issuers are also required to notify NASDAQ of certain other corporate actions. For a complete
list of these notifications, please refer to Regulatory Requirements.
©September 2011, The NASDAQ OMX Group, Inc. All rights reserved. The NASDAQ Stock Market and NASDAQ are
registered trademarks of The NASDAQ OMX Group, Inc.
2
American LegalNet, Inc.
www.FormsWorkFlow.com