Contact Information

Proof of Claims Uploader

Using the provided template, also available here, provide all the requested information with respect to the contact information for the Beneficial Owners, and all of their transactions in Ampio common stock that took place between December 29, 2020 and October 31, 2022, inclusive. Failure to report all such transactions may result in the rejection of their claim.

On the schedules, provide all the requested information with respect to: (1) all of your transactions in Ampio common stock that took place between December 29, 2020 and October 31, 2022, inclusive; (2) the number of shares of Ampio common stock that you held at the close of trading on December 28, 2020; and (3) the number of shares of Ampio common stock that you held at the close of trading on October 31, 2022. Failure to report all such transactions may result in the rejection of your claim.

List each transaction separately and in chronological order, by trade date, beginning with the earliest. You must accurately provide the month, day, and year of each transaction you list.

Do not make any edits to the template as your file will be rejected.

Supporting Documents

For each client submissions you must provide:

1. One signed Proof of Claim Form that will act as the “Master” Proof of Claim for that client;

2. If you are filing on your own behalf or a claim preparer filing on behalf of beneficial owners, you must provide a document verifying that the individual who signed the Proof of Claim form and any supplemental documents is authorized to sign on your behalf.

3. If you are filing on behalf of beneficial owners other than yourself, you must also provide one or more documents that establish proof of authority to file claims on behalf of that client, such as service agreements, power of attorney, engagement agreements, etc;

4. For each transaction you must provide, in addition to the spreadsheet of transactions, copies of stockbroker confirmations slips, stockbroker statements, or other documents adequately evidencing the transactions in Ampio common stock. Failure to provide this documentation could delay verification of your claim or result in rejection of your claim.

IMPORTANT NOTES:

• The document uploader will only accept the following file types: .pdf, .jpg, and .png.

• If you have questions or concerns, please contact the Claims Administrator at broker@AmpioSecuritiesSettlement.com.

Certification & Signature

By signing below, I declare under penalty of perjury under the laws of the United States of America that all of the information I provided on this form and my uploaded file(s) is (are) true, correct and complete to the best of my knowledge.