Appraisal Written Election Form Page 2
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1
2
3
4Must Be Postmarked
IN THE CIRCUIT COURT OF THE FOURTH
No Later Than
JUDICIAL CIRCUIT IN AND FOR DUVAL
Official
October 21, 2014
COUNTY, FLORIDA CIVIL DIVISION
Office
Use
WINNDXE
In re Winn-Dixie Stores, Inc.
Only
Shareholder Litigation
Case No. 16-2011-CA-010616
APPRAISAL WRITTEN ELECTION FORM
Please Type or Print in the Boxes Below
Do NOT use Red Ink, Pencil, or Staples
PART I: CLAIMANT IDENTIFICATION
Last Name
M.I.
First Name
Last Name (Co-Beneficial Owner)
M.I.
First Name (Co-Beneficial Owner)
IRA
Joint Tenancy
Employee
Individual
Other___________
(specify)
Company Name (Beneficial Owner - If Claimant is not an Individual) or Custodian Name if an IRA
Trustee/Asset Manager/Nominee/Record Owner’s Name (If Different from Beneficial Owner Listed Above)
Account#/Fund# (Not Necessary for Individual Filers)
Social Security Number
Taxpayer Identification Number
—
—
—
or
Telephone Number (Primary Daytime)
Telephone Number (Alternate)
—
—
—
—
Email Address
MAILING INFORMATION
Address
Address
City
State
Zip Code
Foreign Province
Foreign Postal Code
Foreign Country Name/Abbreviation
ATP
BE
FL
OP
/
/
FOR CLAIMS
FOR CLAIMS
KE
DR
ME
RE
PROCESSING
PROCESSING
OB
CB
ONLY
ONLY
ICI
EM
ND
SH
*WINNDXEWESECOND*
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