50 Ill. Adm. Code 203.EXHIBIT B
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)
Section 203
Section 203.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)