EXHIBIT 99.5
LANDMARK FINANCIAL CORP.
NUMBER OF SHARES
Fill in the number of shares you wish to purchase and the total amount due.
No fractional shares will be issued. The minimum purchase is 25 shares.
METHOD OF PAYMENT
Check the appropriate box(es). You may pay by check, bank draft or money
order and/or authorize withdrawal from your Landmark Community Bank savings
or certificate account(s). If paying by certified or teller's check, please
make it payable to Landmark Community Bank. Your funds will earn interest at
the Bank's certificate rate per annum until the offering is completed. If
paying by withdrawal, please list the appropriate account number(s); these
designated funds will continue to earn interest from a savings or certificate
account at the same account rate and cannot be withdrawn by you until the
Closing Date, as defined on the front page of the Prospectus.
STOCK REGISTRATION
Print the name(s) in which you want the stock registered. See the reverse
side of this form for registration guidelines.
Enter the social security number (or tax I.D. number) of the registered
owner. Only one number is required.
Indicate the manner in which you wish to take ownership by checking the
appropriate box. If necessary, check other and note ownership such as
corporation, estate or trust. If stock is purchased for a trust, the date of
the trust agreement and trust title must be included.
NASD AFFILIATION
Please refer to the National Association of Securities Dealers, Inc. (NASD)
affiliation section and check the box if applicable. Under the guidelines of
the NASD, members of the NASD and their associates are subject to certain
restrictions on the transfer of securities purchased in accordance with
subscription rights and to certain reporting requirements upon the purchase
of such securities, as established by the NASD.
_____ Check here and initial below if you are a member of the NASD or a
person associated with an NASD member or a member of the immediate family of
any such person to whose support such person contributes directly or
indirectly or if you have an account in which an NASD member or person
associated with an NASD member has a beneficial interest. I agree (i) not to
sell, transfer or hypothecate the stock for a period of 150 days following
issuance, and (ii) to report this purchase order in writing to the applicable
NASD member I am associated with within one day of the payment for the stock.
(Initials)_________
ACKNOWLEDGMENT
Sign and date the form. When purchasing as a custodian, corporate officer,
etc., add your full title to your signature. An additional signature is
required only when payment is by withdrawal from an account that requires
more than one signature to withdraw funds.
DEADLINE
This form along with the Form of Acknowledgment, properly executed and with
the correct payments must be received by Noon, Eastern Time, ___________,
1997 and will be deemed received upon the date and the time of delivery of
the form to our office. Please submit your order using the enclosed
postage-paid envelope or hand-delivering to any Landmark Community Bank
office.
TELEPHONE INFORMATION
Please enter both a daytime and evening telephone number where you may be
reached in the event we cannot execute your order as given.
Daytime Phone ( )______________
Evening Phone ( )______________
STOCK ORDER FORM
Number of Offering Total
Shares Price Amount Due
______ X $ 10.00 =_________
_____ Enclosed is a certified teller's check, bank draft, or money order
payable to Landmark Community Bank for $________.
_____ I authorize withdrawal from the following Landmark Community Bank
account(s):
Account Number(s) Amount
$
$
Total Withdrawal $
_______________________________________________
Name(s) in which your stock is to be registered
_______________________________________________
Name(s) in which your stock is to be registered
_______________________________________________
Address
_______________________________________________
City County
_______________________________________________
State Zip Code
_______________________________________________
Social Security # or Tax ID #
____ Individual _____ Joint Tenants _______ Tenants in Common
_______ Uniform Gift or Transfer to Minors
_______ Other _____________________________________
I (we) acknowledge receipt of the Prospectus and the terms and conditions
described therein. I (we) understand that, after receipt by Landmark
Community Bank, this order may not be modified or withdrawn without the
consent of Landmark Community Bank. Further, I (we) certify that my (our)
purchase does not conflict with the purchase limitations in the Plan of
Conversion, and that the shares being purchased are for my (our) account only
and that there is no present agreement or understanding regarding any
subsequent sale or transfer of such shares. Under penalties of perjury, I
(we) certify that: (1) the Social Security number or Taxpayer Identification
number given above is correct; and (2) I am not subject to backup
withholding. Instructions: You must cross out #2 above if you have been
notified by the Internal Revenue Service that you are subject to withholding
because of under-reporting interest or dividends on your tax return.
I ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT OR ACCOUNT AND IS NOT
FEDERALLY INSURED AND IS NOT GUARANTEED BY INVESTORS FEDERAL OR ANY FEDERAL
OR STATE GOVERNMENT OR AGENCY.
If anyone asserts that this security is federally insured or guaranteed, or
is as safe as an insured deposit, I should call the Northwest Regional
Director of the Office of Thrift Supervision, Jersey City, New Jersey at
(201) 413-1000.
I further certify that, before purchasing the Common Stock of Landmark
Financial Corp., I received a Prospectus. The Prospectus that I received
contains disclosure concerning the nature of the security being offered and
describes the risks involved in the investment. See the "Risk Factors"
section of the Prospectus. In executing this Stock Order Form I affirm that
I have read the Prospectus and am aware of the risks associated with
investing in Landmark Financial Corp. Common Stock.
_____________________________________________________
Signature Date
_____________________________________________________
Additional Signature (if required) Date
FOR ASSISTANCE, PLEASE CALL THE STOCK INFORMATION CENTER, LANDMARK
COMMUNITY BANK, AT (___) ___-____ FROM 9:00 A.M. TO 5:00 P.M., EASTERN TIME,
MONDAY THROUGH FRIDAY.
GUIDELINES FOR REGISTERING STOCK
For reasons of clarity and standardization, the stock transfer industry
has developed uniform stock ownership registration which we will use in
issuing your stock certificate. Common ownership registrations are explained
below. If you have any questions about how your Landmark Financial Corp.
common stock should be registered, see your legal advisor.
To ensure correct registration, please follow the instructions for the
ownership you select.
______________________________________________________________________________
GENERAL INSTRUCTION: - Include the first name, middle initial, and last name
of each person listed. Avoid the use of an initial
in place of the first name.
- Do not use titles such as Mr., Mrs., Dr., etc.
- Omit words that do not affect ownership rights such
as special account, personal property, etc.
______________________________________________________________________________
INDIVIDUAL: Instructions: Print the first name, middle initial, and
last name of the person in whose name the stock is to
be registered. You may not list beneficiaries for this
ownership.
______________________________________________________________________________
JOINT TENANTS: Joint Tenancy with Right of Survivorship identifies two
or more persons as owners of the stock. Upon the death
of one of the owners, ownership automatically passes to
the surviving tenant(s).
Instructions: Print the first name, middle initial, and
last name of each co-tenant. You may not list
beneficiaries for this ownership.
______________________________________________________________________________
UNIFORM GIFTS TO For residents of certain states, stock may be held in
MINORS/UNIFORM the name of a custodian for the benefit of a minor
TRANSFERS TO MINORS: under the Uniform Transfers to Minors Act. For
residents of most other states, stock may be held in a
similar type of ownership under the Uniform Gifts to
Minors Act of the individual states. For either
ownership, the minor is the actual owner of the stock
with the adult custodian being responsible for the
investment until the minor reaches legal age.
Instructions: If you are a New York resident and wish
to register stock in this ownership check Uniform
Transfers to Minors Act. For other states, see your
legal advisor if you are unsure about the correct
registration of your stock.
On the first NAME line, print the first name, middle
initial, and last name of the custodian, with the
abbreviation CUST after the name
Print the first name, middle initial, and last name of
the minor on the second NAME line. Only one custodian
and one minor may be designated.
Please indicate the minor's social security number in
the signature block.
______________________________________________________________________________
OTHER: Generally, fiduciary relationships (such as
Conservatorship, Legal Trust, Guardianship, etc.) are
established under a form of trust agreement or are
pursuant to a court order. Without a legal document
establishing a fiduciary relationship, your stock may
not be registered in a fiduciary capacity.
Instructions: On the first NAME line, print the first
name, middle initial, and last name of the fiduciary if
the fiduciary is an individual. If the fiduciary is a
corporation, list the corporate title on the first NAME
line. Following the name, print the fiduciary title
such as conservator, personal representative, etc.
On the second NAME line, print either the name of the
maker, donor or testator OR the name of the
beneficiary. Following the name, indicate the date and
type of legal document establishing the fiduciary
relationship (agreement, court order, etc.) (Use the
space marked OTHER if necessary). Please contact us if
you have any questions.
EXAMPLE OF A FIDUCIARY REGISTRATION:
John D. Smith Trustee for Tom A. Smith Under Agreement
Dated 06/09/74.
PLEASE NOTE THAT TOTTEN TRUST AND PAYABLE ON DEATH
OWNERSHIPS MAY NOT BE USED IN REGISTERING STOCK.
For example, stock cannot be registered as John Doe
Trustee for Jane Doe or John Doe Payable on Death to
Jane Doe.
______________________________________________________________________________
NASD AFFILIATION: Please refer to the NASD AFFILIATION statement on the
face of this form. If applicable, initial where
indicated and check the box. the National Association
of Securities Dealers, Inc. Interpretation With Respect
to Free-Riding and Withholding (the Interpretation)
restricts the sale of a hot issue (securities that
trade at a premium in the aftermarket) to NASD members,
persons associated with NASD members (i.e., an owner,
director, officer, partner, employee or agent of a NASD
member) and certain members of their families. Such
persons are required to indicate that they will comply
with certain conditions required for an exemption from
the restrictions.
______________________________________________________________________________
F:\CLIENTS\1019 STKORDER.FRM