Form: S-3ASR

Automatic shelf registration statement of securities of well-known seasoned issuers

June 27, 2011

S-3ASR: Automatic shelf registration statement of securities of well-known seasoned issuers

Published on June 27, 2011


Exhibit 99.2

OMEGA HEALTHCARE INVESTORS, INC.
DIVIDEND REINVESTMENT AND COMMON STOCK PURCHASE PLAN
 
REQUEST FOR WAIVER
 

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 $10,000 monthly maximum limit.  Terms used but not defined herein shall have the meanings ascribed thereto in the Plan.
 
This form should be completed each time a participant wishes to make an optional cash investment in excess of the $10,000 monthly maximum limit, and electronically submitted directly to “Attn: DSPP Waiver Request” at waiver.request@omegahealthcare.com. This form will not be considered for acceptance by the Company unless it is completed in its entirety. The Company may accept or reject this Request for Waiver in whole or in part in its sole discretion.
 
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; and (iii) the participant agrees to the terms and conditions of such Plan.
 
Good funds on all accepted Requests for Waiver must be received by Registrar and Transfer Company, the Plan Administrator, via wire transfer by 3:00 p.m. Eastern Time one (1) business day prior to the first day of the applicable pricing period in order for such funds to be invested pursuant to any Request for Waiver. Wire instructions and contact information for the Plan Administrator will be provided upon acceptance of a Request for Waiver.
 
To Be Completed by Participant
 
  Participant Information:      
         
         
  Date   Name of Participant  
         
  Contact Name   Individual Authorized to Transact on Account  
         
   Contact Phone Number        
      Authorized Individual’s Signature  
   Contact Fax Number      
      Participant’s Social Security or Tax ID Number  
   Contact Email address      
         
         
         
   DTC Number      
      Participant’s Address  
         
 
 
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OMEGA HEALTHCARE INVESTORS, INC.
DIVIDEND REINVESTMENT AND COMMON STOCK PURCHASE PLAN
 
REQUEST FOR WAIVER
 
In the event that the threshold price is not satisfied or there are no trades reported for a day in the relevant pricing period, the following information will be used to return the applicable portion of your optional cash investment within three (3) business days after the last day of the pricing period or extended pricing period, if applicable.
 
 
Participant Financial Institution Information:
     
           
  Name of Participant:        
 
 
 
     
  Name of Financial Institution    Bank ABA / Routing Number  
         
  Bank Account Name      Bank Account Number  
         
  Beneficiary Account Name    Beneficiary Account Number  
         
  Participant Instruction – Disposition of Shares      
  ___________        Hold Shares in account      
  ___________        DWAC full shares to DTC# _________________________  
         
 
  Proposed Terms:      
           
  $        
    Optional Cash Investment Requested   Applicable Waiver Discount %  
         
  Pricing Period (beginning and ending dates)    Pricing Period (number of days)  
         
  $        
    Threshold Price   Date and Time Funds Due  
         
  Extension Feature Activated/up to # of days?    Continuous Settlement Feature Activated?  
         
 
  To Be Completed by Omega Healthcare Investors, Inc.      
         
  $        
    Optional Cash Investment Accepted   Approving Signature  
         
      /  
  Date    Name/Title  
 
 
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