POS AM: Post-effective amendment to a registration statement that is not immediately effective upon filing
Published on November 23, 2004
EXHIBIT 99.4
REQUEST FOR WAIVER
OMEGA HEALTHCARE INVESTORS, INC.
DIVIDEND REINVESTMENT AND COMMON STOCK PURCHASE PLAN
To: Omega Healthcare Investors, Inc. Telephone: (410) 427-1700
9690 Deereco Road Facsimile: (410) 427-8822
Timonium, MD 21093
Attn: Dividend Reinvestment & Common Stock Purchase Plan
Pricing Period:--------------------------------------
Investment Date:-------------------------------------
This form is to be used only by participants in the Omega Healthcare Investors,
Inc. Dividend Reinvestment and Common Stock Purchase Plan (the "Plan") who are
requesting authorization from Omega Healthcare Investors, Inc. (the "Company")
to make an optional cash investment under the Plan in excess of the $6,250
monthly maximum limit.
A new form must be completed each month the Participant wishes to make an
optional cash investment in excess of the $6,250 monthly maximum limit. This
form will not be considered for acceptance by the Company unless it is completed
in its entirety. The Company, in its sole discretion, may approve requests for
waiver of the $6,250 monthly maximum limit for optional cash investments.
The Participant submitting this form hereby certifies that (i) the information
contained herein is true and correct as of the date of this form; (ii) the
Participant has received and read a current copy of the Prospectus relating to
the Plan; (iii) the Participant agrees to the terms and conditions of such Plan;
(iv) the optional cash investment is being made by and on behalf of the
Participant for the Participant's own account; and (v) the Participant shall
submit a copy of this Request for Waiver (approved by the Company) to EquiServe
Trust Company, N.A. ("EquiServe"), the administrator of the Plan, via facsimile
at (201) 222-4758, at the same time an enrollment authorization form (if
required) and the optional cash purchase are submitted by the Participant.
GOOD FUNDS ON ALL ACCEPTED REQUESTS FOR WAIVER MUST BE RECEIVED BY THE PLAN
ADMINISTRATOR NO LATER THAN 2:00 P.M., EASTERN TIME, ON THE BUSINESS DAY PRIOR
TO THE FIRST DAY THE RELEVANT PRICING PERIOD IN ORDER FOR SUCH FUNDS TO BE
INVESTED ON THE RELEVANT INVESTMENT DATE.
- --------------------------------------------------------------------------------
o REQUEST FOR WAIVER - To be completed by the Participant (please print
except for signature):
- --------------------------------- ----------------------------------------
Participant's Name U.S. Taxpayer I.D. or Social Security
Number(s)
- ------------------------------------ ----------------------------------------
Participant's Signature Date Address
- ------------------------------------ ----------------------------------------
Print name as it should appear in City State Zip
stock records
$----------------------------------- ----------------------------------------
Optional Cash Investment Amount Phone Number
Requested
- ------------------------------------ ----------------------------------------
Contact Person Facsimile Number
Shares acquired through the Plan will be held in an account with EquiServe
unless otherwise instructed below. If you do not have an existing Plan account,
one will be established for you.
|_| Hold all shares in my Plan account.
Existing Account Number (if applicable):
---------------------------
|_| Issue certificate for full shares.
|_| DWAC full shares to DTC #
---------------
EquiServe's DTC # is 1291, Attn: Investment Services **
** If requesting to DWAC shares, please include an additional $100 fee per DWAC
in your payment.
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REQUEST FOR WAIVER
OMEGA HEALTHCARE INVESTORS, INC.
DIVIDEND REINVESTMENT AND DIRECT STOCK PURCHASE PLAN
Please select the manner of payment below:
|_| By Wire Transfer
Wire Instructions:
Financial Institution: Bank One Chicago
Bank ABA #: 071000013
Bank Account Name: EquiServe
Bank Account Number: 9300195
Reference: Waiver funds for Omega Healthcare, Inc., Attn:
Investment Services
|_| By Check
Overnight Mailing Instructions:
EquiServe
Attn: Frank Tirabasso, 3rd Floor Suite 4675
525 Washington Blvd
Jersey City, New Jersey 07310
(201) 222-4505
In the event that the threshold price is not satisfied or there are no
trades reported for one or more days in the Pricing Period, the following
information will be used to return the applicable portion of your optional cash
investment as soon as practicable after the Pricing Period.
- --------------------------------------------------------------------------------
Participant's Name Name of Financial Institution
- --------------------------------------------------------------------------------
Bank ABA/Routing Number Bank Account Name
- --------------------------------------------------------------------------------
Bank Account Number Reference
- --------------------------------------------------------------------------------
o APPROVAL SECTION - To be completed by Omega Healthcare Investors, Inc.:
Pricing Period: |_| Waiver Approved |_| Waiver Not Approved
Discount Rate*: % Threshold Price (per share):$
---------------- -------------
(* Please note that the discount is applied after the final investment
price is determined)
Approved Optional Cash Investment Amount:$
--------------------------------------
Omega Healthcare Investors, Inc.:
- --------------------------------------------------------------------------------
Signature and Title Date
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