PLUS THERAPEUTICS, INC. - FORM S-1/A - EX-99.5 - FORM OF BENEFICIAL OWNER ELECTION FORM - May 10, 2016

Attached files

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S-1/A - CYTORI THERAPEUTICS FORM S1 - PLUS THERAPEUTICS, INC.forms1.htm
EX-99.1 - FORM OF INSTRUCTION RGHTS CERTIFICATES - PLUS THERAPEUTICS, INC.ex99_1.htm
EX-4.28 - FORM OF WARRANT AGREEMENT BETWEEN CYTORI THERAPEUTICS INC AND BROADRIDGE CORPORATE ISSUER SOLUTIONS INC - PLUS THERAPEUTICS, INC.formofwarrantagreement.htm
EX-99.3 - FORM OF LETTER TO BROKER, DEALER, BANKS AND OTHER NIMINEES - PLUS THERAPEUTICS, INC.ex99_3.htm
EX-99.6 - FORM OF NIMINEE HOLDER CERTIFICATION - PLUS THERAPEUTICS, INC.ex99_6.htm
EX-4.27 - FORM OF SERIES R WARRANT UNDERLYING THE UNITS - PLUS THERAPEUTICS, INC.formofseriesrwarrant.htm
EX-99.4 - FORM OF BROKER LETTER TO CLIENTS WHO ARE BENEFICIAL HOLDERS - PLUS THERAPEUTICS, INC.ex99_4.htm
EX-4.26 - FORM OF NON TRANSFERABLE SUBSCRIPTION RIGHTS CERTIFICATE - PLUS THERAPEUTICS, INC.fomofnontransferable.htm
EX-8.1 - TAX OPINION OF DLA PIPER LLP US - PLUS THERAPEUTICS, INC.taxopinionofdlapiperllp.htm
EX-5.1 - OPINION OF DLA PIPER LLP US - PLUS THERAPEUTICS, INC.opinionofdlapiper.htm
EX-23.1 - CONSENT OF KPMG LLP INDEPENDENT REGISTERED PUBLIC ACCOUNTING FIRM - PLUS THERAPEUTICS, INC.consentofkpmg.htm
EX-1.1 - FORM OF DEALER MANAGER AGREEMENT BY AND BETWEEN CYTORI THERAPEUTICS, INC MAXIM GROUP LLC - PLUS THERAPEUTICS, INC.formofdealermanager.htm
EX-99.2 - FORM OF LETTER TO SHAREHOLDERS WHO ARE RECORD HOLDERS - PLUS THERAPEUTICS, INC.ex99_2.htm
Exhibit 99.5
FORM OF
BENEFICIAL OWNER ELECTION FORM
CYTORI THERAPEUTICS, INC.
The undersigned acknowledge(s) receipt of your letter and the enclosed materials referred to therein relating to the rights offering (the "Rights Offering") by Cytori Therapeutics, Inc., a Delaware corporation (the "Company"), of non-transferable subscription rights (the "Subscription Rights") to purchase units (the "Units"), each such Unit comprised of a share of the Company's common stock, $0.001 par value ("Common Stock"), and 0.5 of a warrant. Each whole Warrant will be exercisable for one share of Common Stock.
This will instruct you whether to exercise Subscription Rights to purchase Units distributed with respect to the shares of the Common Stock held by you for the account of the undersigned, pursuant to the terms and subject to the conditions set forth in the Prospectus. (Check the applicable boxes and provide all required information.)
 
☐
 
Please DO NOT EXERCISE SUBSCRIPTION RIGHTS for Units.
 
☐
 
Please EXERCISE SUBSCRIPTION RIGHTS for Units as set forth below:
 
                         
No. of Units
    
 
Per Unit
Subscription Price
 
Payment
                
Basic Subscription Right
[____]
        
X
$[____]
=
$[____]
                      
Over-Subscription Privilege
[____]
        
X
$[____]
=
$[____]
           
          
Total Payment Required
  
$[____]
If you spoke with a broker who solicited such exercise, please indicate the name of the person you spoke with:  .
 
☐
 
Payment in the following amount is enclosed $______ (must match Total Payment Required above)
 
☐
 
Please deduct payment from the following account maintained by you as follows:
               
     
Type of Account:
  
 
 
    
               
     
Account No.:
  
 
 
    
               
     
Amount to be deducted: $
  
 
 
    
I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:
 
 
—
 
irrevocably elect to purchase the number of Units indicated above upon the terms and conditions specified in the Prospectus; and
 
—
 
agree that if I (we) fail to pay for the shares I (we) have elected to purchase, the exercise will be invalid.
 
         
   
Signature:
  
 
 
       
     
 
Name:
  
 
 
       
     
 
Title:
  
 
 
       
     
 
Address:
  
 
 
 
 
 
       
     
 
Telephone:
  
 
 
         
     
Date:
  
 
  
, 2016

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