Exhibit 99.5
NEW PEOPLES BANKSHARES, INC.
BENEFICIAL OWNER ELECTION FORM
The undersigned acknowledge(s) receipt of your letter and the enclosed materials relating to the grant of non-transferable rights to purchase Shares (consisting of one share of common stock, par value $2.00 per share, and a warrant to purchase one (1) share of common stock for each five (5) Shares purchased in this offering), of New Peoples Bankshares, Inc. (the “Company”).
I (we) hereby instruct you as follows:
(CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION)
Box 1.¨ Please DO NOT EXERCISE RIGHTS for Shares.
Box 2.¨ Please EXERCISE RIGHTS for Shares as set forth below:
A. Number of Shares Being Purchased: |
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| B. Total Exercise Price Payment Required: |
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Payments should be made in U.S. Dollars and: (1) by personal check drawn on a U.S. Bank; (2) a bank check drawn on New Peoples Bank, Inc.; or (3) by wire transfer. Checks should be made payable to Registrar and Transfer Company – New Peoples Escrow. Wire instructions are attached.
Basic Subscription Right
| I exercise rights | X | 1.665 | (no. of Shares) | |||||
(no. of your rights) | (ratio) | |||||||
| Therefore, I apply for | X | $ .00 = | $ | |||||
(no. of Shares) | (subscription price) | (amount enclosed or wired) | ||||||
Over-Subscription Privilege
If you fully exercise your Basic Subscription Right, and wish to subscribe for additional Shares up to the total number of unsubscribed Shares, you may exercise your Over-Subscription Privilege. The Over-Subscription Privilege is subject to the rights of other eligible shareholders. If sufficient Shares are available, the Company will seek to honor the over-subscription requests in full. If, however, over-subscription requests exceed the number of unsubscribed Shares, the Company will allocate the unsubscribed Shares among subscribers exercising their Over-Subscription Privilege by multiplying the number of Shares requested by each subscriber through the exercise of their Over-Subscription Privilege by a fraction that equals (x) the number of Shares available to be purchased through Over-Subscription Privileges divided by (y) the total number of Shares requested by all subscribers through the exercise of their Over-Subscription Privileges.
Accordingly, my maximum Over-Subscription Privilege is:
16,666,667 |
| Shares | ||||||
| (total offered Shares) | (total no. of Shares subscribed for above) | (maximum unsubscribed Shares) |
Therefore, I apply for:
| X $1.50 |
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| (no. of your over-subscription Shares subscribed for) | (subscription price) | (additional amount enclosed or wired) | ||||||
| Total Payment Required = | $ | |||||||
Box 3.¨ Payment in the following amount is enclosed or wired.
$
(The total of the above Box 3 must equal the Total Payment Required.)
I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:
| • | irrevocably elect to purchase the number of Shares indicated above upon the terms and conditions specified in the prospectus; and |
| • | agree that if I (we) fail to pay for the Shares I (we) have elected to purchase, the exercise will be invalid. |
| Name of beneficial owner(s): |
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| Signature of Beneficial Owner(s): |
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If you arc signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or another acting in a fiduciary or representative capacity, please provide the following information:
| Name: |
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| Capacity: |
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| Address (including Zip Code): |
| Telephone Number: |
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Wiring Instructions:
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| For Benefit of: | Registrar and Transfer Company | |
| As Subscription Agent for Various Holders | ||
| Account Number: | 276-053-5977 | |
| Bank: | TD Bank | |
| 6000 Atrium Way | ||
| Mt. Laurel, NJ 08054 | ||
| ABA Number: | 031-201-360 | |
