Appraisal Written Election Form (Page 4 of 4) in pdf

3. The claimant(s) has (have) not submitted any other claim covering the same purchases, acquisitions, sales, or

holdings of Winn-Dixie common stock and knows (know) of no other person having done so on his/her/its/their behalf;

4. The claimant(s) submits (submit) to the jurisdiction of the Court with respect to his/her/its/their claim and for purposes

of enforcing the releases set forth herein;

5. I (we) agree to furnish such additional information with respect to this Appraisal Written Election Form as the Appraisal

Escrow Agent or the Court may require;

6. I (we) acknowledge that the claimant(s) will be bound by and subject to the terms of the Stipulation and any judgment

that may be entered in the Action, including the releases and covenants set forth herein; and

7. I (we) certify that I (we) am (are) not subject to backup withholding under the provisions of Section 3406(a)(1)(c) of

the Internal Revenue Code.

Note: If you have been notified by the Internal Revenue Service that you are subject to backup withholding, please strike the

language that you are not subject to backup withholding in certification (7) above and fill in the circle.

The Internal Revenue

Service does not require your consent to any provision other than the certification required to avoid backup withholding.

UNDER THE PENALTIES OF PERJURY, I (WE) CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME (US) ON

THIS FORM IS TRUE, CORRECT, AND COMPLETE AND THAT THE DOCUMENTS SUBMITTED HEREWITH ARE TRUE AND

CORRECT COPIES OF WHAT THEY PURPORT TO BE.

Executed this _______________ day of _________________________ in __________________________________________

(Month/Year)

(City/State/Country)

_____________________________________________

(Sign your name here)

_____________________________________________

(Type or print your name here)

_____________________________________________

(Capacity of person(s) signing, e.g.,

Beneficial Purchaser, Executor or Administrator)

ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME.

THANK YOU FOR YOUR PATIENCE.

Reminder Checklist:

1. Sign the release and certification below. If the Appraisal

6. You will not automatically receive a confirmation that

Written Election Form is being submitted on behalf of

the Appraisal Escrow Agent received your Appraisal

joint claimants, both claimants must sign it.

Written Election Form. If you would like a confirmation,

please send your Appraisal Written Election Form

2. Send $1 per participating Share by check or money

via

U.S.

certified

mail,

return

receipt

requested.

order to the Appraisal Escrow Agent with your signed

and completed Appraisal Written Election Form. Checks

7. If your address changes between the time of filing your

and money orders should be made payable to “The

Appraisal Written Election Form and completion of

Winn-Dixie Appraisal Fund.” Do not send cash.

Settlement, or if the notice you received about the

Settlement was sent to an old or incorrect address, please

3. Do not highlight any portion of the Appraisal Written

send the Appraisal Escrow Agent written notification of

Election Form or supporting documents.

your new address. If you change your name, please

4. Attach copies of acceptable supporting documents. Do

inform the Appraisal Escrow Agent.

not send original documents, including, but not limited to,

8. If you have any questions or concerns regarding the Appraisal

original stock certificates, because the Appraisal Escrow

Written Election Form, please contact the Appraisal Escrow

Agent cannot return these items to you.

Agent at the below address, call 1-877-430-6524, or visit

5. Keep copies of the Appraisal Written Election Form and

supporting documents that you submit for your records.

THIS APPRAISAL WRITTEN ELECTION FORM AND $1 PER SHARE DEPOSIT

MUST BE POSTMARKED NO LATER THAN October 21, 2014 AND MUST BE MAILED TO:

In re Winn-Dixie Stores, Inc. Shareholder Litigation

Claims Administrator/Appraisal Escrow Agent

c/o Gilardi & Co. LLC

P.O. Box 8040

San Rafael, CA 94912-8040

*WINNDXEWEFOURTH*

Appraisal Written Election Form Page 4

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