EXHIBIT 4.4
Enrollment Form for:
WICOR, Inc. Direct Stock Purchase and Dividend Reinvestment Plan
This form when WICOR, Inc. Shareholder Are you a current
completed and signed, Services registered
should be mailed in P. O. Box 750 shareholder?
the envelope provided Pittsburgh, PA 15230-9625 YES [_] NO [_]
to:
1. ACCOUNT REGISTRATION. Complete either section A, B, C, or D. Print
Clearly in CAPITAL LETTERS.
A. INDIVIDUAL OR JOINT ACCOUNT. (Enter only the Social Security
number for the name under which Dividends should be reported.)
__________________________________________________________________________
Owner's Name
______________________________ _________________________________________
Owner's Social Security number Owner's date of birth
(used for tax reporting) (Month/Day/Year)
__________________________________________________________________________
Joint Owner's Name
____________________________ The account will be registered
Joint Owner's Social Security Number "Joint Tenants with Rights of
(used for tax reporting) Survivorship" and not as tenants
in common unless you check
a box below:
[ ] Tenants in common
[ ] Tenants by entirety
[ ] Community property
B. CUSTODIAL ACCOUNT/GIFT TO A MINOR (An Enrollment Form is
required for each minor. Only one custodian per account is allowed.)
__________________________________________________________________________
Custodian's Name
__________________________________________________________________________
Minor's Name
____________________________ ____________________ ____________
Minor's Social Security number Minor's date of birth Custodian's
(required) (Month/Day/Year) state
C. TRUST (Please check only one of the trustee types)
[ ] Person as trustee [ ] Organization as trustee
__________________________________________________________________________
Trustee: Individual or Organization Name
__________________________________________________________________________
and Co-trustee's Name, if applicable
__________________________________________________________________________
Name of Trust
__________________________________________________________________________
For the benefit of
________________________________ ____________________________________
Trust Taxpayer Identification Number Date of Trust
(required) (Month/Day/Year)
D. ORGANIZATION OR BUSINESS ENTITY Check one:
[ ] Corporation [ ] Partnership [ ] Other
__________________________________________________________________________
Name of Entity
_________________________________________
Taxpayer Identification Number (required)
ADDRESS
__________________________________________________________________________
Mailing Address (including apartment or box number)
_________________________________ _____ _____________________________
City State Zip
(___ )____________________________ (___)_______________________________
Home phone Work phone
For mailing address outside the U.S.:
___________________________________ _____________________ ______________
Country of residence Province Routing or
postal code
3. INITIAL/OPTIONAL CASH INVESTMENTS (Make checks payable to The Chase
Manhattan Bank)
[_] As a NEW investor I wish to [_] As a CURRENT registered
enroll in the Plan by making an shareholder I wish to make
initial investment. Enclosed an optional cash investment.
is my check or money order for Enclosed is my check or
$_______________. (Initial money order for $__________.
Cash Investments must be at (Minimum $100 with the
least $500, but cannot exceed maximum not to exceed
$10,000.) $10,000 per month.)
Please allow 2 weeks to receive your account statement. Your cancelled
check serves as your acknowledgment.
NEW INVESTORS MUST COMPLETE SECTIONS 1, 2 & 7.
4. DIVIDEND REINVESTMENT (At least 10 shares must be reinvested)
You may choose to reinvest all or part of the dividends paid on WICOR
Stock. If no box is selected, The Chase Manhattan Bank will
automatically remit any dividends to you in cash.
[_] Full Dividend Reinvestment - reinvest the dividends on ALL
shares.
or
[_] Partial Dividend Reinvestment - Please reinvest the dividends on
_______________ percent of my shares. 100% of your dividends
will be reinvested if a percentage is not indicated.
[_] If this is a gift/transfer per page ___ of the prospectus,
please check this box and the account will be automatically
enrolled in dividend reinvestment.
5. SAFEKEEPING
Common stock certificates deposited for safekeeping in your account
must be in the same registration as your Plan account. Unless
otherwise indicated in Section 4, dividends on all shares deposited for
safekeeping will be paid in cash.
[_] Please accept the enclosed certificate(s) for deposit to my
account.
certificate number number of shares
_____________________________ ___________________________
_____________________________ ___________________________
_____________________________ ___________________________
_____________________________ ___________________________
NUMBER OF CERTIFICATES T O T A L
6. ELECTRONIC DIVIDEND DEPOSITS/AUTOMATIC INVESTMENTS
A. Authorization Agreement (Please verify that your financial
institution participates in these programs)
[_] DEPOSIT OF CASH DIVIDENDS ELECTRONICALLY
I hereby authorize to have my dividends deposited automatically in my
checking or savings account. If this option is not selected, your
dividend check will be automatically mailed to your address of record.
[_] AUTOMATIC OPTIONAL CASH INVESTMENT
I hereby choose to make additional investments in WICOR Stock by
authorizing automatic monthly deductions from my checking or savings
account. Upon receipt of a properly completed form, the Administrator
will deduct the amount, indicated below from your account. These
deductions and automatic investments will continue monthly until you
notify ChaseMellon Shareholder Services to change or discontinue them.
Should your account contain insufficient funds to cover the authorized
deduction, no deduction or investment will occur. In such event, you
may be charged a fee by your financial institution for insufficient
funds.
I hereby authorize The Chase Manhattan Bank and the Financial
Institution indicated below to deduct from my account $_______.00 per
month ($100 minimum) and apply amounts so deducted toward the purchase
of WICOR Shares under the account designated. (Note: Deductions will
occur on or about the 15th of each month.)
B. ACCOUNT INFORMATION
This information will be used for [_] Direct Deposit of Dividends
[_] Automatic Investments
Please X
Tape your voided check or deposit slip here
[_] Checking account (PLEASE DO NOT STAPLE)
Financial Institution routing information.
[_] Savings account For deposits or withdrawals to your checking
account, please tape a voided check so the
Administrator may obtain account information.
For deposits or withdrawals to a savings
account, please tape a preprinted deposit slip.
If neither a voided check or preprinted deposit slip is
available, please complete the boxes below.
Financial Institution Financial Institution account
routing number number
7. ACCOUNT AUTHORIZATION SIGNATURE/SUBSTITUTE FORM W-9. W-8 (REQUIRED)
[_] REQUEST FOR TAXPAYER [_] CERTIFICATE OF FOREIGN
IDENTIFICATION NUMBER STATUS
(Substitute Form W-9) (Substitute Form W-8)
I am a U.S. citizen or a resident I am an exempt foreign citizen. I
alien. I certify, under certify, under penalties of
penalties of perjury, that the perjury, that for dividends, I am
Taxpayer Identification or Social not a U.S. citizen or resident
Security number in Section 1 is alien (or I am filing for a
correct (or I am waiting for a foreign corporation, partnership,
number to be issued to me). estate, or trust) and I am an
Cross out the following if not exempt foreign person. I have
true. I am not subject to backup entered in Section 2 of this
withholding because: (a) I am enrollment form the country where
exempt from backup withholding, I reside permanently for income-
or (b) I have not bee notified by tax purposes.
the Internal Revenue Service that
I am subject to backup [_] FOR ORGANIZATIONS AND
withholding as a result of BUSINESS ENTITIES EXEMPT
failure to report all interest or FROM BACKUP WITHHOLDING
dividends, or (c) the IRS has I qualify for exemption and my
notified me that I am no longer account will not be subject to tax
subject to backup withholding. reporting and backup withholding.
THE SIGNATURE(S) BELOW INDICATE THAT I/WE HAVE READ THE WICOR, Inc. DIRECT
STOCK PURCHASE AND DIVIDEND REINVESTMENT PLAN'S PROSPECTUS AND AGREE TO
THE TERMS.
Signature of account owner(s): Date:
__________________________________________________________________________
If you need assistance, Please call ChaseMellon Shareholder Services at
1-800-621-9609