Published on December 22, 2016
EXHIBIT 99.6
RAVE RESTAURANT GROUP, INC.
NOMINEE HOLDER CERTIFICATION
NOMINEE HOLDER CERTIFICATION
The undersigned, a bank, broker, trustee, depositary or other nominee of subscription rights (the "Rights") to purchase 4% Convertible Senior Notes due 2022, par value $100 ("Notes"), of Rave Restaurant Group, Inc. (the "Company"), pursuant to the offering described in the Company's prospectus dated [_________], 2017 (the "Prospectus"), hereby certifies to the Company and to Securities Transfer Corporation, as Subscription Agent for such offering, that (1) the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the number of Rights specified below pursuant to the Basic Subscription Privilege (as defined in the Prospectus) and on behalf of beneficial owners of Rights who have subscribed for the purchase of additional Notes pursuant to the Over-Subscription Privilege (as defined in the Prospectus), listing separately below each such exercised Basic Subscription Privilege and the corresponding Over-Subscription Privilege (without identifying any such beneficial owner), and (2) each such beneficial owner's Basic Subscription Privilege has been exercised in full:
Number of Shares Owned
on the Record Date |
Rights Exercised Pursuant
to Basic Subscription Privilege |
Number of Notes
Subscribed for Pursuant to
Over-Subscription Privilege
|
1. _______________________
|
_______________________
|
_______________________
|
2. _______________________
|
_______________________
|
_______________________
|
3. _______________________
|
_______________________
|
_______________________
|
4. _______________________
|
_______________________
|
_______________________
|
5. _______________________
|
_______________________
|
_______________________
|
6. _______________________
|
_______________________
|
_______________________
|
7. _______________________
|
_______________________
|
_______________________
|
8. _______________________
|
_______________________
|
_______________________
|
9. _______________________
|
_______________________
|
_______________________
|
Provide the following information if applicable:
______________________________________
Depository Trust Company ("DTC")
Participant Number
[PARTICIPANT]
By:__________________________________
Name:
Title:
______________________________________
Depository Trust Company ("DTC")
Participant Number
[PARTICIPANT]
By:__________________________________
Name:
Title:
_____________________________________
DTC Basic Subscription Confirmation Number(s)
DTC Basic Subscription Confirmation Number(s)