EXHIBIT 99.6
FORM OF BENEFICIAL OWNER ELECTION
The undersigned acknowledge(s) receipt of your letter and the enclosed materials referred to therein relating to the offering of 5.5%/8.5% Series A Convertible Preferred Stock, with a par value of $0.001 per share (the “Preferred Stock”) of The Providence Service Corporation (the “Company”).
With respect to any instructions to exercise (or not to exercise) Rights, the undersigned acknowledges that this form must be completed and returned such that it will actually be received by you by 5:00 p.m., New York City Time, on , 2014, the last business day prior to the scheduled expiration date of the Rights Offering of , 2014 (which may be extended by the Company in its sole discretion).
This will instruct you whether to exercise Rights to purchase shares of Preferred Stock of the Company distributed with respect to the shares of the Company’s Common Stock held by you for the account of the undersigned, pursuant to the terms and subject to the conditions set forth in the Prospectus and the related “Instructions for Use of The Providence Service Corporation Subscription Rights Certificates.”
Box 1. ¨ Please DO NOT EXERCISE RIGHTS for shares of Preferred Stock.
Box 2. ¨ Please EXERCISE RIGHTS for shares of Preferred Stock as set forth below.
The number of Rights for which the undersigned gives instructions for exercise under the Subscription Right should not exceed the number of Rights that the undersigned is entitled to exercise.
| Number of Shares of Preferred Stock | Per Share Subscription Price | Payment | ||||||||||
Subscription Right: | x | $
| $100.00 = |
| $ | (Line 1) | ||||||
| Total Payment Required | $ | |||||||||||
| | (Line 1 must equal total of amounts in Boxes 2 and 3.) | | ||||||||||
Box 2. ¨ Payment in the following amount is enclosed $ .
Box 3. ¨ Please deduct payment from the following account maintained by you as follows:
| Type of Account | Account No. | |||
Amount to be deducted: | $ | |||
| Signature(s) | ||||
| Please type or print name(s) below: | ||||
Date: , 2014
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