Proxy
Statement Pursuant to Section 14(a) of the Securities Exchange Act of
1934
|
|
Filed
by the registrant O
|
|
Filed
by a party other than the registrant Q
|
|
Check
the appropriate box:
|
|
Q
|
Preliminary
proxy statement
|
Q
|
Confidential,
for use of the Commission only (as permitted by Rule
14a-6(e)(2))
|
O
|
Definitive
proxy statement
|
Q
|
Definitive
additional materials
|
Q
|
Soliciting
material pursuant to '
240.14a-12
|
TIMBERLAND
BANCORP, INC.
|
|
(Name
of registrant as specified in its charter)
|
|
(Name
of person(s) filing proxy statement, if other than the
registrant)
|
|
Payment
of filing fee (Check the appropriate box):
|
|
O
|
No
fee required.
|
Q
|
Fee
computed on table below per Exchange Act Rules 14a-6(i)(1) and
0-11.
|
(1)
|
Title
of each class of securities to which transaction
applies:
|
N/A
|
|
(2)
|
Aggregate
number of securities to which transactions applies:
|
N/A
|
|
(3)
|
Per
unit price or other underlying value of transaction computed pursuant to
Exchange Act Rule 0-11:
|
N/A
|
|
(4)
|
Proposed
maximum aggregate value of transaction:
|
N/A
|
|
(5)
|
Total
fee paid:
|
N/A
|
|
Q
|
Fee
paid previously with preliminary materials:
|
N/A
|
|
Q
|
Check
box if any part of the fee is offset as provided by Exchange Act Rule
0-11(a)(2) and identify the filing for which the offsetting fee was paid
previously. Identify the previous filing by registration
statement number, or the Form or Schedule and the date of its
filing.
|
(1)
|
Amount
previously paid:
|
N/A
|
|
(2)
|
Form,
schedule or registration statement no.:
|
N/A
|
|
(3)
|
Filing
party:
|
N/A
|
|
(4)
|
Date
filed:
|
N/A
|
|
|
Sincerely, | |
/s/ Jon C. Parker | |
Jon C. Parker | |
Chairman of the Board |
Proposal
1.
|
Election
of two directors to each serve for a term of three years and one director
to serve for a term of two years.
|
Proposal
2.
|
Advisory
approval of the compensation of our named executive
officers.
|
Proposal
3.
|
Ratification
of the Audit Committee=s
selection of McGladrey & Pullen, LLP as our independent auditor for
2010.
|
BY ORDER OF THE BOARD OF DIRECTORS | |
/s/Dean J. Brydon | |
DEAN J. BRYDON | |
CORPORATE SECRETARY |
Date: | Tuesday, January 26, 2010 | |
|
Time:
|
1:00
p.m., local time
|
Place:
|
Hoquiam
Timberland Library, 420 7th
Street, Hoquiam, Washington
|
Proposal 1.
|
Election
of two directors to each serve for a term of three years and one director
to serve for a term of two years.
|
Proposal 2.
|
Advisory
approval of the compensation of our named executive
officers.
|
Proposal 3.
|
Ratification
of the Audit Committee=s
selection of McGladrey & Pullen, LLP as our independent auditor for
2010.
|
$
|
Proxy
Statement;
|
$
|
proxy
card; and
|
$
|
Annual
Report to Shareholders.
|
$
|
submitting
a new proxy with a later date;
|
$
|
notifying
the Corporate Secretary of Timberland in writing before the annual meeting
that you have revoked your proxy;
or
|
$
|
voting
in person at the annual meeting.
|
$
|
those
persons or entities (or groups of affiliated person or entities) known by
management to beneficially own more than five percent of Timberland=s
common stock other than directors and executive
officers;
|
$
|
each
director and director nominee of
Timberland;
|
$
|
each
executive officer of Timberland or Timberland Bank named in the Summary
Compensation Table appearing under AExecutive
Compensation@ below
(known as Anamed
executive officers@);
and
|
$
|
all
current directors and executive officers of Timberland and Timberland Bank
as a group.
|
Number
of Shares
|
Percent
of Shares
|
|||
Name
|
Beneficially
Owned (1)
|
Outstanding
(%)
|
||
Beneficial
Owners of More Than 5%
|
||||
Timberland
Bank Employee Stock Ownership and 401(k) Plan (2)
|
885,807
|
12.6%
|
||
624
Simpson Avenue
|
||||
Hoquiam,
Washington 98550
|
||||
Dimensional
Fund Advisors LP
|
611,575
(3)
|
8.7
|
||
6300
Bee Cave Road
|
||||
Austin,
Texas 78746
|
||||
Royce
& Associates, LLC
|
469,200
(4)
|
6.7
|
||
1414
Avenue of the Americas
|
||||
New
York, New York 10019
|
||||
Directors
|
||||
Andrea
M. Clinton
|
20,121
|
*
|
||
Larry
D. Goldberg
|
2,000
|
*
|
||
James
C. Mason
|
20,287
|
*
|
||
Jon
C. Parker
|
49,553
|
*
|
||
Ronald
A. Robbel
|
54,701
|
*
|
||
David
A. Smith
|
78,511
|
1.1
|
||
Named
Executive Officers
|
||||
Michael
R. Sand (5)
|
138,449
|
2.0
|
||
Dean
J. Brydon
|
37,940
|
*
|
||
Robert
A. Drugge
|
18,581
|
*
|
||
John
P. Norawong
|
18,387
|
*
|
||
Michael
J. Scott
|
--
|
*
|
||
All
Executive Officers and Directors as a Group (13 persons)
|
464,941
|
6.5
|
||
___________ |
(1)
|
The amounts shown also include
the following number of shares which the indicated individuals have the
right to acquire within 60 days of the voting record date through the
exercise of stock options: Mr. Robbel, 44,548 shares;
Mr. Smith, 56,638 shares;
and all executive officers and directors as a group, 101,186
shares.
|
(2)
|
Represents
shares held in the ESOP portion of the ESOP and 401(k) Plan. As
of the voting record date, 550,754 shares in the ESOP portion of the plan
have been allocated to participants=
accounts including 69,288 shares to executive officers which is included
in their totals above.
|
(3)
|
Based
solely on a Schedule 13G/A dated February 9, 2009, regarding shares owned
as of December 31, 2008. According to this filing, Dimensional Fund
Advisors LP (ADimensional@), an
investment adviser registered under Section 203 of the Investment Advisors
Act of 1940, furnishes investment advice to four investment companies
registered under the Investment Company Act of 1940, and serves as
investment manager to certain other commingled group trusts and separate
accounts (collectively, the AFunds@). In
its role as investment advisor or manager, Dimensional possesses
investment and/or voting power over the shares reported, and may be deemed
to be the beneficial owner of the shares held by the Funds. However, the
shares reported are owned by the Funds. Dimensional disclaims beneficial
ownership of these shares.
|
(4)
|
Based
solely on a Schedule 13G/A dated January 29, 2009, regarding shares owned
as of December 31, 2008. According to this filing, various accounts
managed by Royce & Associates, LLC, an investment registered under
Section 203 of the Investment Advisors Act of 1940, have the right to
receive or the power to direct the receipt of dividends from or the
proceeds from the sale of the shares reported. One account, Royce Value
Trust, Inc. an investment company registered under the Investment Company
Act of 1940 and managed by Royce & Associates, LLC, held all of the
shares reported.
|
(5)
|
Mr.
Sand is also a director of
Timberland.
|
Age
as of
|
Year
First Elected or
|
Term
to
|
||||
Name
|
September
30, 2009
|
Appointed
Director (1)
|
Expire
|
|||
Board
Nominees
|
||||||
Michael
R. Sand
|
55
|
1993
|
2013
(2)
|
|||
David
A. Smith
|
54
|
2000
|
2013
(2)
|
|||
Larry
D. Goldberg
|
63
|
2009
|
2012
(2)
|
|||
Directors
Continuing in Office
|
||||||
Jon
C. Parker
|
60
|
1992
|
2011
|
|||
James
C. Mason
|
54
|
1993
|
2011
|
|||
Andrea
M. Clinton
|
52
|
1996
|
2012
|
|||
Ronald
A. Robbel
|
68
|
2002
|
2012
|
|||
____________ |
(1)
|
For
years prior to 1998, includes prior service on the Board of Directors of
Timberland Bank. Each member of our Board of Directors is also
a member of the Board of Directors of the Bank.
|
(2)
|
Assuming
election or re-election.
|
$
|
Adjustable rate mortgage for
personal residence: interest rate is 1.5% above Timberland
Bank=s cost
of funds (subject to a floor of 5.25% for loans originated after August 1,
2006); no loan fee is charged.
|
$
|
Fixed rate mortgage for
personal residence: interest rate is set at the current Federal
Home Loan Mortgage Corporation par rate; no loan fee is
charged.
|
$
|
Consumer loans: normal
interest rates apply; no loan fee is
charged.
|
$
|
Personal computer
purchases: interest rate is currently 3.0%; no loan fee is
charged.
|
Name
|
Type
of
Loan
|
Amount
Involved
in
the
Transaction
($)(1)
|
Amount
Outstanding
as
of
September
30,
2009
($)
|
Principal
Paid
During
the
Year
Ended
September
30,
2009
($)
|
Interest
Paid
During
the
Year
Ended
September
30,
2009
($)
|
Interest
Rate
(%)
|
||||||
David
A. Smith
|
First
Mortgage
|
421,968
|
412,117
|
9,851
|
17,749
|
4.250
|
||||||
Jon
C. Parker
|
First
Mortgage
|
194,462
|
191,344
|
3,118
|
10,135
|
5.250
|
||||||
Robert
A. Drugge
|
First
Mortgage
|
327,198
|
322,402
|
4,796
|
17,064
|
5.250
|
||||||
Kathie
M. Bailey
|
First
Mortgage
|
146,152
|
141,294
|
4,858
|
6,120
|
4.250
|
||||||
Home
Equity
Line
of Credit
|
41,475
|
41,368
|
107
|
1,129
|
5.875
|
|||||||
_________ |
(1)
|
Consists
of the largest aggregate amount of principal outstanding during the year
ended September 30, 2009.
|
Name
|
Fees
Earned or
Paid
in Cash
($)
|
Stock
Awards
($)(1)(2)
|
Option
Awards
($)(1)(3)
|
All
Other
Compensation
($)(4)
|
Total
($)
|
|||||
Andrea
M. Clinton
|
25,000
|
4,579
|
--
|
600
|
30,179
|
|||||
Larry
D. Goldberg (5)
|
2,000
|
--
|
--
|
--
|
2,000
|
|||||
Clarence
E. Hamre (6)
|
10,000
|
1,748
|
--
|
10,282
|
22,030
|
|||||
James
C. Mason
|
27,000
|
4,579
|
--
|
600
|
32,179
|
|||||
Jon
C. Parker
|
25,000
|
4,579
|
--
|
600
|
30,179
|
|||||
Ronald
A. Robbel
|
29,000
|
4,579
|
1,351
|
600
|
35,530
|
|||||
David
A. Smith
|
29,000
|
4,579
|
--
|
600
|
34,179
|
|||||
Harold
L. Warren (7)
|
2,000
|
267
|
113
|
--
|
2,380
|
|||||
______________ |
(1)
|
Represents
the dollar amount of expense recognized for financial statement reporting
purposes in fiscal 2009 for awards made in fiscal 2009 and prior years and
being earned by the director ratably over the vesting period of the award.
Amounts are calculated pursuant to the provisions of Financial Accounting
Standards Board Statement of Financial Accounting Standards No. 123
(revised 2004), AShare-Based
Payment@
(AFAS
123R@). For
a discussion of valuation assumptions, see Note 15 of the Notes to
Consolidated Financial Statements in Timberland=s
Annual Report on Form 10-K for the year ended September 30,
2009.
|
(2)
|
Consists
of an award to each non-employee director, other than Mr. Goldberg, of 440
shares of restricted stock on October 24, 2006 (aggregate grant date fair
value of $8,026), 545 shares of restricted stock on October 23, 2007
(aggregate grant date fair value of $8,006) and 1,168 shares of restricted
stock on December 4, 2008 (aggregate grant date fair value of
$8,234).
|
(3)
|
Consists
of an award to each of Mr. Robbel and Mr. Warren of 28,340 stock options
granted on March 13, 2003 with an aggregate grant date fair value of
$64,556.
|
(4)
|
Consists
of restricted stock dividends. For Mr. Hamre, also consists of payments
under his deferred compensation/non-competition agreement, as described
below.
|
(5)
|
Mr.
Goldberg was appointed to the Board of Directors effective as of September
23, 2009.
|
(6)
|
Mr.
Hamre retired from the Board of Directors on February 28,
2009.
|
(7)
|
Mr.
Warren retired from the Board of Directors on October 31,
2008.
|
$
|
to
attract and retain key executives who are vital to our long-term
success;
|
$
|
to
provide levels of compensation competitive with those offered throughout
the banking industry and consistent with our level of performance;
and
|
$
|
to
motivate executives to enhance long-term shareholder value by building
their equity interest in
Timberland.
|
$
|
base
salary;
|
$
|
annual
bonus; and
|
$
|
long-term
incentive compensation.
|
|
(1)
|
Discuss,
evaluate and review with senior risk officers all the SEO compensation
plans and make all reasonable efforts to ensure that these plans do not
encourage SEOs to take unnecessary and excessive risks that threaten the
value of Timberland;
|
|
(2)
|
Discuss,
evaluate and review with senior risk officers the risks all employee
compensation plans pose to the Company and make all reasonable efforts to
limit those identified risks; and
|
|
(3)
|
Discuss,
evaluate and review all employee compensation plans to revise or eliminate
any features that encourage the manipulation of reported earnings of
Timberland to enhance the compensation of any
employee.
|
Name
and Principal Position
|
Year
|
Salary
($)
|
Bonus
($)
|
Stock
Awards
($)(1)
|
All
Other
Compen-
sation
($)(2)
|
Total ($)
|
||||||
Michael
R. Sand
|
2009
|
210,000
|
--
|
4,342
|
16,939
|
231,281
|
||||||
President
and Chief Executive
|
2008
|
210,000
|
20,812
|
2,693
|
18,450
|
251,955
|
||||||
Officer
of Timberland and
|
2007
|
200,000
|
40,607
|
--
|
60,798
|
301,405
|
||||||
Timberland
Bank
|
||||||||||||
Dean
J. Brydon
|
2009
|
157,500
|
--
|
4,342
|
9,605
|
171,447
|
||||||
Executive
Vice President,
|
2008
|
157,500
|
10,406
|
2,693
|
12,206
|
182,805
|
||||||
Chief
Financial Officer and
|
2007
|
120,000
|
20,000
|
--
|
39,161
|
179,161
|
||||||
Secretary
of Timberland and
|
||||||||||||
Timberland
Bank
|
||||||||||||
Robert
A. Drugge
|
2009
|
165,000
|
--
|
50,794
|
16,605
|
232,399
|
||||||
Executive
Vice President and
|
2008
|
157,500
|
14,000
|
44,067
|
18,099
|
233,666
|
||||||
Business
Banking Manager
|
2007
|
150,000
|
16,000
|
24,633
|
8,476
|
199,109
|
||||||
of
Timberland Bank
|
||||||||||||
John
P. Norawong
|
2009
|
165,000
|
--
|
50,794
|
14,842
|
230,636
|
||||||
Executive
Vice President and
|
2008
|
157,500
|
14,000
|
44,067
|
16,595
|
232,162
|
||||||
Community
Banking Division
|
2007
|
150,000
|
16,000
|
24,633
|
3,000
|
193,633
|
||||||
Manager
of Timberland Bank
|
||||||||||||
Michael
J. Scott (3)
|
2009
|
120,000
|
2,000
|
--
|
5,455
|
127,455
|
||||||
Senior
Vice President and
|
2008
|
86,250
|
5,000
|
--
|
1,363
|
92,613
|
||||||
Chief
Credit Administrator
|
2007
|
--
|
--
|
--
|
--
|
--
|
||||||
of
Timberland Bank
|
||||||||||||
(1)
|
Represents
the dollar amount of expense recognized for financial statement reporting
purposes in fiscal 2009 for awards made in fiscal 2009 and prior years and
being earned by the officer ratably over the vesting period of the award.
Amounts are calculated pursuant to the provisions of FAS 123R. For a
discussion of valuation assumptions, see Note 15 of the Notes to
Consolidated Financial Statements in Timberland=s
Annual Report on Form 10-K for the year ended September 30,
2009.
|
(2)
|
Please
see the table below for more information on the other compensation paid to
our executive officers in the year ended September 30,
2009.
|
(3)
|
Mr.
Scott joined Timberland on January 1,
2008.
|
Name
|
401(k)
Plan
Contribu-
tion
($)
|
ESOP
Contribu-
tion
($)
|
Restricted
Stock
Dividends
($)
|
Life
Insurance
Premiums
($)
|
Country
Club
Dues
($)
|
Personal
Use
of
Company
Vehicle
($)
|
Total
($)
|
|||||||
Michael
R. Sand
|
11,500
|
--
|
702
|
2,052
|
2,356
|
329
|
16,939
|
|||||||
Dean
J. Brydon
|
8,395
|
--
|
702
|
508
|
--
|
--
|
9,605
|
|||||||
Robert
A. Drugge
|
8,950
|
--
|
5,358
|
2,297
|
--
|
--
|
16,605
|
|||||||
John
P. Norawong
|
8,950
|
--
|
5,358
|
534
|
--
|
--
|
14,842
|
|||||||
Michael
J. Scott
|
3,000
|
--
|
--
|
2,455
|
--
|
--
|
5,455
|
Name
|
Grant
Date
|
Option
Awards:
Number
of Shares of Stock
or
Units (#)(1)
|
Grant
Date Fair
Value
of Stock and Option
Awards
($)
|
|||
Michael
R. Sand
|
N/A
|
--
|
--
|
|||
Dean
J. Brydon
|
N/A
|
--
|
--
|
|||
Robert
A. Drugge
|
N/A
|
--
|
--
|
|||
John
P. Norawong
|
N/A
|
--
|
--
|
|||
Michael
J. Scott
|
10/26/2009
|
2,500
|
5,063
|
(1)
|
Option
awards vest ratably over the five-year period from the grant date, with
the first 20% vesting one year after the grant
date.
|
Option
Awards
|
Stock
Awards (1)
|
||||||||||||||
Number
of
Securities
Underlying
Unexercised
|
Number
of
Securities
Underlying
Unexercised
|
Option
|
Option
|
Number
of
Shares
or
Units
of Stock
That
|
Market
Value
of
Shares or
Units
of Stock
|
||||||||||
Grant
|
Options
(#)
|
Options
(#)
|
Exercise
|
Expiration
|
Have
Not
|
That
Have Not
|
|||||||||
Name
|
Date
|
Exercisable
|
Unexercisable
|
Price
($)
|
Date
|
Vested
(#)
|
Vested
($)
|
||||||||
Michael
R. Sand
|
10/23/07
|
--
|
--
|
--
|
--
|
800
|
3,712
|
||||||||
10/1/08
|
--
|
--
|
--
|
--
|
1,000
|
4,640
|
|||||||||
Dean
J. Brydon
|
10/23/07
|
--
|
--
|
--
|
--
|
800
|
3,712
|
||||||||
10/1/08
|
--
|
--
|
--
|
--
|
1,000
|
4,640
|
|||||||||
Robert
A. Drugge
|
07/25/06
|
--
|
--
|
--
|
--
|
2,400
|
11,136
|
||||||||
06/26/07
|
--
|
--
|
--
|
--
|
3,600
|
16,704
|
|||||||||
10/23/07
|
--
|
--
|
--
|
--
|
800
|
3,712
|
|||||||||
06/24/08
|
--
|
--
|
--
|
--
|
2,400
|
11,136
|
|||||||||
10/1/08
|
--
|
--
|
--
|
--
|
2,000
|
9,280
|
|||||||||
John
P. Norawong
|
07/25/06
|
--
|
--
|
--
|
--
|
2,400
|
11,136
|
||||||||
06/26/07
|
--
|
--
|
--
|
--
|
3,600
|
16,704
|
|||||||||
10/23/07
|
--
|
--
|
--
|
--
|
800
|
3,712
|
|||||||||
06/24/08
|
--
|
--
|
--
|
--
|
2,400
|
11,136
|
|||||||||
10/1/08
|
--
|
--
|
--
|
--
|
2,000
|
9,280
|
|||||||||
Michael
J. Scott
|
--
|
--
|
--
|
--
|
--
|
--
|
--
|
Option
Awards
|
Stock
Awards
|
||||||||
Number
of
|
Number
of
|
||||||||
Shares
|
Value
|
Shares
|
Value
|
||||||
Acquired
on
|
Realized
on
|
Acquired
on
|
Realized
on
|
||||||
Name
|
Exercise
(#)
|
Exercise
($)
|
Vesting
(#)
|
Vesting
($)
|
|||||
Michael
R. Sand
|
1,343
|
672
|
200
|
1,100
|
|||||
Dean
J. Brydon
|
20,000
|
19,800
|
200
|
1,100
|
|||||
Robert
A. Drugge
|
--
|
--
|
3,200
|
14,456
|
|||||
John
P. Norawong
|
--
|
--
|
3,200
|
14,456
|
|||||
Michael
J. Scott
|
--
|
--
|
--
|
--
|
Death
($)
|
Disability
($)
|
||
Michael R.
Sand
|
|||
Employment
Agreement
|
--
|
--
|
|
Equity
Plans
|
8,352
|
8,352
|
|
Dean J.
Brydon
|
|||
Employment
Agreement
|
--
|
--
|
|
Equity
Plans
|
8,352
|
8,352
|
|
Robert A.
Drugge
|
|||
Equity
Plans
|
51,968
|
51,968
|
|
John P.
Norawong
|
|||
Equity
Plans
|
51,968
|
51,968
|
|
Michael J.
Scott
|
|||
Equity
Plans
|
--
|
--
|
$
|
The
Audit Committee has completed its review and discussion of the 2009
audited financial statements with
management;
|
$
|
The
Audit Committee has discussed with the independent auditor, McGladrey
& Pullen, LLP, the matters required to be discussed by Statement on
Auditing Standards (ASAS@) No.
61, Communication with
Audit Committees, as amended, as adopted by the Public Company
Accounting Oversight Board in Rule
3200T;
|
$
|
The
Audit Committee has received written disclosures and the letter from the
independent auditor required by applicable requirements of the Public
Company Accounting Oversight Board regarding the independent auditor=s
communications with the audit committee concerning independence, and has
discussed with the independent auditor the independent auditor=s
independence; and
|
$
|
The
Audit Committee has, based on its review and discussions with management
of the 2009 audited financial statements and discussions with the
independent auditor, recommended to the Board of Directors that
Timberland=s
audited financial statements for the year ended September 30, 2009 be
included in its Annual Report on Form
10-K.
|
Year
Ended
|
|||
September
30,
|
|||
2009
|
2008
|
||
Audit
Fees
(1)
|
$263,388
|
$249,172
|
|
Audit-Related
Fees
(2)
|
10,000
|
11,500
|
|
Tax
Fees
(3)
|
26,216
|
15,856
|
|
___________ |
(1)
|
Includes
fees for the annual audit and quarterly reviews of the consolidated
financial statements. Also includes fees related to compliance
with Section 404 of the Sarbanes-Oxley Act of 2002, regarding our internal
control over financial reporting.
|
(2)
|
Audit-related fees
for the year ended September 30, 2009 are related to the consent for our
Form S-3 filing. Audit related fees for the year ended September 30,
2008 are principally for the audits of our employee benefit
plans.
|
(3)
|
Includes
fees for the preparation of federal and state tax
returns.
|
BY ORDER OF THE BOARD OF DIRECTORS | |
/s/Dean J. Brydon | |
DEAN J. BRYDON | |
CORPORATE SECRETARY |
FOR
|
WITHHELD
|
|||
1.
|
The
election as director of the nominees listed below
|
[ ]
|
[ ]
|
|
(except
as marked to the contrary below).
|
||||
Three-year
term:
|
||||
Michael
R. Sand
|
||||
David
A. Smith
|
||||
Two-year
term:
|
||||
Larry
D. Goldberg
|
||||
INSTRUCTIONS: To
withhold your vote
|
||||
for
any individual nominee, write the
|
||||
nominee=s name
on the line below.
|
||||
FOR
|
AGAINST
|
ABSTAIN
|
||
2.
|
Advisory
approval of the compensation of Timberland Bancorp, Inc.=s
named executive officers.
|
[ ]
|
[ ]
|
[ ]
|
3.
|
The
ratification of the Audit Committee=s
selection of McGladrey & Pullen, LLP as the independent auditor for
the year ending September 30, 2010.
|
[ ]
|
[ ]
|
[ ]
|
3.
|
In
their discretion, upon such other matters as may properly come before the
meeting.
|
____________________________________
|
____________________________________
|
PRINT
NAME OF SHAREHOLDER
|
PRINT
NAME OF SHAREHOLDER
|
____________________________________
|
____________________________________
|
SIGNATURE
OF SHAREHOLDER
|
SIGNATURE
OF SHAREHOLDER
|