EX-99.6 15 nt10013019x2_ex99-6.htm EXHIBIT 99.6
Exhibit 99.6
THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANY’S PROSPECTUS DATED      (THE “PROSPECTUS”) AND ARE INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM D.F. KING, THE INFORMATION AGENT, BY CALLING (212) 269-5550 (BANKERS AND BROKERS) OR (800) 290-6432 (ALL OTHERS) OR BY EMAIL AT AP@DFKING.COM.
AMPCO-PITTSBURGH CORPORATION
UNITS SUBSCRIBED FOR UPON
EXERCISE OF SUBSCRIPTION RIGHTS
NOMINEE HOLDER CERTIFICATION
The undersigned, a bank, broker, trustee, depository or other nominee holder of subscription rights (the “Subscription Rights”) to purchase units (the “Units,” and each, a “Unit”), each Unit consisting of     share(s) of common stock of AMPCO-PITTSBURGH CORPORATION, a Pennsylvania corporation (the “Company”), par value $1.00 per share (“Common Stock”) and a Series A warrant exercisable for     shares of Common Stock at an exercise price of $    (the “Warrants” and each, a “Warrant”), pursuant to the rights offering described in the Company’s prospectus dated       (the “Prospectus”), hereby certifies to the Company and Broadridge Corporate Issuer Solutions, Inc., as subscription agent for the rights offering, that (1) the undersigned has exercised on behalf of the beneficial owners thereof (which may include the undersigned), Subscription Rights for the number of Units specified below pursuant to the basic right (as described in the Prospectus), and on behalf of beneficial owners of subscription rights who have subscribed for the purchase of additional Units pursuant to the over-subscription privilege (as described in the Prospectus), listing separately below a number of Units corresponding to such beneficial owners’ exercised basic right and a number of Units corresponding to such beneficial owners’ exercised over-subscription privilege (without identifying any such beneficial owner), and (2) to the extent any beneficial owner has exercised their oversubscription privilege, each such beneficial owner’s basic right has been exercised in full:
 
NUMBER OF SHARES OWNED
ON RECORD DATE
NUMBER OF UNITS
SUBSCRIBED FOR
PURSUANT TO BASIC RIGHT
NUMBER OF UNITS SUBSCRIBED FOR PURSUANT TO
OVER-SUBSCRIPTION PRIVILEGE
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
Name of Bank, Broker, Trustee, Depository or Other Nominee:
By:
 
 
 
Authorized Signature
 
Name:
 
 
 
(Please print or type)
 
Title:
 
 
 
(Please print or type)
 

Provide the following information if applicable:
Depository Trust Company (“DTC”) Participant Number
Participant:
By:
 
 
 
Authorized Signature
 
Name:
 
 
 
(Please print or type)
 
Title:
 
 
 
(Please print or type)
 
DTC Subscription Confirmation Number(s)