Exhibit 99.5
BENEFICIAL OWNER ELECTION FORM
relating to
BLUE VALLEY BAN CORP.
RIGHTS TO PURCHASE COMMON STOCK
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NOTE FROM YOUR NOMINEE: YOU SHOULD RETURN THIS FORM ON A TIMELY BASIS TO ENSURE
THAT WE ARE ABLE TO ACT PURSUANT TO YOUR INSTRUCTIONS. ACCORDINGLY, IF YOU ELECT
TO EXERCISE YOUR RIGHTS, PLEASE ENSURE THAT ALL REQUIRED FORMS AND PAYMENTS ARE
ACTUALLY RECEIVED BY US PRIOR TO 5:00 P.M., EASTERN TIME ON DECEMBER 4, 2008,
THE LAST BUSINESS DAY PRIOR TO THE SCHEDULED EXPIRATION DATE OF THE RIGHTS
OFFERING TO ENSURE THAT WE HAVE SUFFICIENT TIME TO DELIVER SUCH FORMS AND
PAYMENTS TO THE RELEVANT SUBSCRIPTION AGENT BY 5:00 P.M., EASTERN TIME ON
DECEMBER 5, 2008, THE SCHEDULED EXPIRATION DATE.
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The undersigned acknowledge(s) receipt of your letter and the enclosed
materials relating to the rights offering by Blue Valley Ban Corp. (the
"Company"), of nontransferable rights to purchase shares of common stock, par
value $1.00 per share, of the Company ("Common Stock"), including the
accompanying prospectus (the "Prospectus"). The undersigned also acknowledge(s)
that the exercise of rights is not revocable.
I (we) hereby instruct you as follows:
(CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION)
Box 1. |_| Please DO NOT EXERCISE RIGHTS to purchase shares of Common Stock
Box 2. |_| Please EXERCISE RIGHTS to purchase shares of Common Stock as set
forth below:
EXERCISE OF RIGHTS (Complete if Box 2 is checked):
Basic Subscription Right Rights x .1352 =
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(no. of rights) (no. of shares to be purchased)
Over-Subscription Right Rights x .1352 =
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(no. of rights) (no. of shares to be purchased)
Therefore, I apply for x $18.00 = $
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(no. of new shares) (subscription price) (payment required)
|_| Payment is enclosed: $_____________
|_| Please deduct payment of $__________ from the following account
maintained by you as follows:
Type of Account: ______________________ Account No.: ______________________
Complete if Box 1 or 2 checked:
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 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 that I
(we) have elected to purchase, you may exercise any remedies available
to you under law.
Name of beneficial owner(s):
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Signature of beneficial owner(s):
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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:
Name:
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Capacity:
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Address (including Zip Code):
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Telephone Number:
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