Forced Conversion Statement for 12.0% Unsecured Convertible Promissory Note – Midwest Energy Emissions Corp.
This document is a forced conversion statement related to the 12.0% Unsecured Convertible Promissory Note issued by Midwest Energy Emissions Corp. It directs the company to issue and deliver common stock to the noteholder as a result of a mandatory conversion, in accordance with the terms of the note. The holder must provide their name, signature, address, and tax identification number to complete the conversion process.
EXHIBIT 10.24
FORCED CONVERSION STATEMENT
As a result of the forced conversion of the 12.0% Unsecured Convertible Promissory Note (the “Note”) of Midwest Energy Emissions Corp. (the “Company”) registered in the name of the undersigned into common stock, par value $0.001 per share, of the Company in accordance with the terms of the Note, the undersigned hereby directs that the securities issuable upon conversion be issued and delivered to the undersigned.
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| Print Name of Holder |
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| Signature and title (if applicable) |
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| Address |
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| Soc. Sec. or Tax ID No. |
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