Exhibit 99.5

 

THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANY’S PROSPECTUS DATED JANUARY [●], 2022 (THE “PROSPECTUS”) AND ARE INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM BROADRIDGE CORPORATE ISSUER SOLUTIONS, INC., THE SUBSCRIPTION AGENT, BY CALLING (855) 793-5068. THE PROSPECTUS IS ALSO AVAILABLE ON THE COMPANY’S WEBSITE AT WWW.INTERPACE.COM.

 

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 January [●], 2022 (“Prospectus”), hereby certifies to the Company and Broadridge Corporate Issuer Solutions, Inc., the subscription agent for the rights offering, that (1) the undersigned has exercised on behalf of the beneficial owners thereof (which may include the undersigned), the number of Subscription Rights specified below pursuant to the basic subscription right (as defined in the Prospectus), and on behalf of beneficial owners of Subscription Rights who have subscribed for the purchase of additional shares of Common Stock pursuant to the over-subscription right (as defined in the Prospectus), listing separately below each such exercised basic subscription right and the corresponding over-subscription right (without identifying any such beneficial owner), and (2) each such beneficial owner’s basic subscription right has been exercised in full:

 

  

NUMBER OF SHARES AND/OR WARRANTS

HELD ON RECORD

DATE

  

NUMBER OF WHOLE

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):