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the same account rate and cannot be withdrawn by you until the Closing Date, as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 Shares Offering Price Total 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 LANDMARK COMMUNITY BANK 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 Northeast 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 the
TRANSFERS TO name of a custodian for the benefit of a minor
MINORS: MINORS/UNIFORM under the Uniform Transfers to Minors Act.
For residents of most other states, stock may be held in a
similar type of ownershipunder 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.
_______________________________________________________________________________