Exhibit 99.5
THE
TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANY’S PROSPECTUS DATED
INTERPACE BIOSCIENCES, INC.
SHARES OF COMMON STOCK
ISSUABLE 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 shares of common stock, par value $0.01 per share (“Common Stock”), of Interpace Biosciences, Inc., a
Delaware corporation (the “Company”), pursuant to the rights offering described in Company’s prospectus dated
NUMBER OF SHARES AND/OR WARRANTS HELD ON RECORD DATE | NUMBER
OF SHARES SUBSCRIBED FOR PURSUANT TO BASIC SUBSCRIPTION RIGHT | NUMBER OF SHARES SUBSCRIBED FOR PURSUANT TO OVER-SUBSCRIPTION RIGHT | ||||||||||
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): |