Exhibit 99.6
BENEFICIAL OWNER ELECTION FORM
The undersigned acknowledge(s) receipt of the letter and the enclosed materials relating to the grant of non-transferable rights to purchase shares of common stock, par value $0.01 per share, of Federal Trust Corporation.
I (we) hereby instruct you as follows:
(CHECK THE ONE APPLICABLE BOX AND PROVIDE ALL REQUIRED INFORMATION)
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Box 1. | | ¨ | | | Please DO NOT EXERCISE RIGHTS to purchase shares of Common Stock. |
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Box 2. | | ¨ | | | Please EXERCISE RIGHTS to purchase shares of Common Stock as set forth below: |
A. | Number of Shares Being Purchased: |
| (subject to the purchase and ownership limitations described in the Prospectus section entitled “The Rights Offering – Limit on How Many Shares of Common Stock You May Purchase in the Rights Offering”) |
B. | Aggregate Subscription Price Payment Required: $ |
Basic Subscription Privilege
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I exercise | | (number of rights) | | rights x XX = (ratio) | | (number of new shares) (round down to nearest whole share) |
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I subscribe for | | (number of new shares) | | x $ XX = (subscription price) | | $ (amount payable) |
Over-Subscription Privilege
If you fully exercise your Basic Subscription Privilege and wish to subscribe for additional shares, you may exercise your Over-Subscription Privilege.
STEP 1: | Determine the maximum number of available unsubscribed shares: |
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XX (total no. of shares offered less shares to be owned by standby purchasers) | | - = (number of new shares subscribed above) | | shares (maximum available number of unsubscribed shares) | | |
(OVER)
STEP 2. | Exercise Over-Subscription Privilege (up to the above maximum): |
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(number of over-subscription shares subscribed) | | x $ XX = (subscription price) | | $ (additional amount payable) | | |
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Total Shares = | | ___________________ |
| | (sum of Basic plus Over-Subscription amounts) |
| | (Must equal the total shares specified on line “A” above.) |
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Total Payment Required = | | $__________________ |
| | (sum of Basic plus Over-Subscription amounts) |
| | (Must equal the total payment specified on line “B” above.) |
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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 of Common Stock indicated on line “A” above, upon the terms and conditions specified in the prospectus; and |
| • | | agree that if I (we) fail to pay for the shares of Common Stock I (we) have elected to purchase, you may exercise any remedies available to you under law. |
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Name(s) of beneficial owner(s): | | |
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Signature(s) of beneficial owner(s): | | |
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Telephone Number: | | |
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If you are 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: |
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Name: |
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Capacity (Full Title): |
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Address (including Zip Code): |
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Telephone Number: |
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