EX-99.(A)(1)(C) 4 d392153dex99a1c.htm FORM OF NOTICE OF WITHDRAWAL Form of Notice of Withdrawal

Exhibit 99(a)(1)(C)

 

LOGO

 

NOTICE OF WITHDRAWAL OF TENDER REGARDING

SHARES HELD IN FS INVESTMENT CORPORATION

 

TENDERED PURSUANT TO THE OFFER TO PURCHASE DATED AUGUST 20, 2012

THE OFFER AND WITHDRAWAL RIGHTS WILL EXPIRE AT, AND

THIS NOTICE OF WITHDRAWAL MUST BE RECEIVED BY FS

INVESTMENT CORPORATION, EITHER BY MAIL, COURIER OR

PERSONAL DELIVERY BEFORE 5:00 P.M., CENTRAL TIME, ON

SEPTEMBER 25, 2012, UNLESS THE OFFER IS EXTENDED.

Complete this Notice of Withdrawal and return to the following address:

 

For delivery by regular mail:    For delivery by registered, certified or
express mail, by overnight courier or by
personal delivery:

FS Investment Services

c/o DST Systems, Inc.

P.O. Box 219095

Kansas City, MO 64121-9095

  

FS Investment Services

c/o DST Systems, Inc.

430 W. 7th Street

Kansas City, MO 64105

You are responsible for confirming that this Notice of Withdrawal is received by

FS Investment Corporation at the address above.


Ladies and Gentlemen:

The undersigned hereby withdraws the tender of its shares of common stock, par value $0.001 per share (the Shares), of FS Investment Corporation (the Company) that previously was submitted by the undersigned in a Letter of Transmittal dated,                     , 2012.

 

A.    STOCKHOLDER(S) INFORMATION

Beneficial Holder(s) Information

 

 

Name                                                                     

      

Name                                                                  

 

Address 

          

Address 

   
  (street)          (street)
              
                    (city/state)                                      (zip)       

                    (city/state)                                          (zip)

 

Social Security or Tax ID No.                          

      

Social Security or Tax ID No.                        

 

Telephone No.                                                    

      

Telephone No.                                                  

Shares are held through an individual retirement account or other qualified pension account:  ¨  Yes  ¨  No

Registered Holder Information (if different than above; print name exactly as it appears on the subscription agreement or as indicated on the stock ledger maintained by the Company’s transfer agent)

 

Name of Registered Holder                                                                                                                        

                                                                 (e.g., custodian if shares are registered in the name of a custodian)

Address                                                                                                                                                             

                    (street)                                                                (city/state)                                                                          (zip)

Tax ID No.                                                          Telephone No.                                                                   

 

B.    WITHDRAWAL REQUEST (select one option)

¨    All Shares owned as of the Expiration Date

¨    Other number of Shares:                             

[Signature page follows]


    C.  AUTHORIZED SIGNATURES

The undersigned recognizes that upon the receipt on a timely basis of this Notice of Withdrawal of Tender, properly executed, the Shares previously tendered will not be purchased by the Company.

If Shares are registered in the name of a custodian, the custodian of the Shares must execute this Notice of Withdrawal, and the beneficial owner of the Shares hereby authorizes and directs the custodian of the Shares to execute this Notice of Withdrawal.

  Beneficial Holder Signature:

 

 
                     

Signature – Beneficial Holder

         

Signature – Beneficial Holder

 
                     

Print Name of Beneficial Holder

          Print Name of Beneficial Holder
 
             

Title of Signatory if Acting in a Representative Capacity

         

Title of Signatory if Acting in a Representative Capacity

 
                 

Date

            Date  
           
Registered Holder Signature (if different than above; print name exactly as it appears on the subscription agreement or as indicated on the stock ledger maintained by the Company’s transfer agent):          
           
               

Signature – Registered Holder

       
               

Print Name of Registered Holder

       
         

Title of Signatory

       
             

Date

           

 

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