(DRS) Statement - Computershare

.THE SAMPLE COMPANY9th Floor, North Tower, 100 University AvenueToronto, Ontario, M5J 2Y1Telephone 1-800-564-6253www.computershare.com/serviceSam Sample& Mary Sample JT TEN1234 Any StreetAnytown ON X0X 0X0000001Holder Account NumberC1234567890Brokers: To process deposits correctly throughCDSX, enter the Holder Account Numberpreceded by a '9', e.g. 9C1234567890, in thecertificate number field.Company IDXXXXStatement PeriodJan 01, 2008 - Dec 31, 2008SAMPLE COMPANY - Direct Registration (DRS) StatementAccount Information: Date Dec 31, 2008 (Excludes transactions pending settlement)Opening DirectRegistration BalanceJan 01, 2008Unrestricted DirectRegistration BalanceDec 31, 2008Restricted DirectRegistration BalanceDec 31, 2008Closing DirectRegistration BalanceDec 31, 2008CUSIPClass Description0.00000050.000000220.000000270.000000999999999CLASS DESCRIPTION« Register today for Investor Centre, Computershare’s online self-service account management tool for shareholders at www.computershare.com/investorcentrecanada »SAMPLE COMPANY is Incorporated Under the Canada Business Corporations Act« Register today for Investor Centre, Computershare's online self-service account management tool for shareholders at www.computershare.com/ca/register »Please see subsequent page(s) for Restriction DetailsIMPORTANT INFORMATION RETAIN FOR YOUR RECORDS.This advice is your record of the securities transaction affecting your holdings recorded on the books of the Issuer as part of the book-based Direct Registration System (DRS). It isneither a negotiable instrument nor a security. You can transfer or sell your book-based DRS holdings represented by this advice by presenting this advice to your broker along withwritten instructions/stock power. If the Issuer’s incorporating documents and governing legislation entitle security holders to receive certificates representing their holdings, this advice isalso a non-transferable written acknowledgement of your right to receive such a certificate in respect of your holdings.Upon request, the Issuer will furnish to any security holder, without charge, a full statement of the designations, rights (including rights under an Issuer Rights Agreement, if any),preferences and limitations of the securities of each class and series authorized to be issued and the authority of the Board of Directors to divide the securities into series and todetermine and change rights, preferences and limitations of any class or series.The assets in your account on the books of the Issuer are part of the Direct Registration System. Such assets are not deposits of Computershare and are not insured by the CanadaDeposit Insurance Corporation or any other government agency.Please see important PRIVACY NOTICE at the end of this statementPage 1 of 212345ACPUQC01.E.INT/000001/i1234

The following section outlines in detail a record of activity involving either the application and/or expiration of the restrictions applied to your balance of Restricted Direct RegistrationSecurities/Units of Sample Company.Balance Affected: 220.000000 CUSIP: 999999999 Class Description: CLASS DESCRIPTIONDate Restriction Issued Restriction:Restriction Details:Status Date of Expiry:Jan 1, 2008 Dated Legend UNLESS PERMITTED UNDER SECURITES LEGISLATION, THEHOLDER OF THIS SECURITY MUST NOT TRADE THE SECURITYBEFORE THE DATE THAT IS 4 MONTHS AND A DAY AFTERJANUARY 1, 2008EnduringUNTIL THE SEPARATION TIME (AS DEFINED IN THE RIGHTS AGREEMENT REFERRED TO BELOW), THIS CERTIFICATE ALSO EVIDENCES AND ENTITLES THE HOLDERHEREOF TO CERTAIN RIGHTS AS SET FORTH IN A SHAREHOLDER RIGHTS PLAN AGREEMENT, DATED AS OF JULY 24, 2007 (THE "RIGHTS AGREEMENT"), BETWEEN XYZINC. (THE "COMPANY") AND COMPUTERSHARE INVESTOR SERVICE INC., AS RIGHTS AGENT, AS AMENDED FROM TIME TO TIME, THE TERMS OF WHICH ARE HEREBYINCORPORATED HEREIN BY REFERENCE AND A COPY OF WHICH MAY BE INSPECTED DURING NORMAL BUSINESS HOURS AT THE PRINCIPAL OFFICE OF THECORPORATION. UNDER CERTAIN CIRCUMSTANCES, AS SET OUT IN THE RIGHTS AGREEMENT, THE RIGHTS MAY BE AMENDED, REDEEMED, MAY EXPIRE, MAY BECOMENULL AND VOID OR MAY BE EVIDENCED BY SEPARATE CERTIFICATES AND NO LONGER EVIDENCED BY THIS CERTIFICATE. THE CORPORATION WILL MAIL OR ARRANGEFOR THE MAILING OF A COPY OF THE RIGHTS AGREEMENT TO THE HOLDER OF THIS CERTIFICATE WITHOUT CHARGE AS SOON AS PRACTICABLE AFTER THE RECEIPTOF A WRITTEN REQUEST THEREFOR.Privacy NoticePrivacy Notice: Computershare is committed to protecting your personal information. In the course of providing services to you and our corporate clients, we receive non-public personalinformation about you - from transactions we perform for you, forms you send us, other communications we have with you or your representatives, etc. This information could include yourname, address, social insurance number, securities holdings and other financial information. We use this to administer your account, to better serve your and our clients’ needs and forother lawful purposes relating to our services. Some of your information may be transferred to servicers in the U.S.A. for data processing and/or storage. We have prepared a Privacy Codeto tell you more about our information practices, how your privacy is protected and how to contact our Chief Privacy Officer. It is available at our website, computershare.com, or by writingus at 100 University Avenue, Toronto, Ontario, M5J 2Y1.Page 2 of 212345A