Exhibit 99.5
BENEFICIAL OWNER ELECTION FORM
I (we) acknowledge receipt of your letter and the enclosed materials relating to
the offering of subscription rights ("Rights") to purchase shares of common
stock (the "Common Stock") of Fidelity Federal Bancorp (the "Company").
In this form, I (we) instruct you whether to exercise Rights distributed with
respect to the Common Stock held by you for my (our) account, pursuant to the
terms and subject to the conditions set forth in the prospectus dated July 12,
2002 (the "Prospectus").
BOX 1. [ ] Please do not exercise Rights for shares of the Common Stock.
BOX 2. [ ] Please exercise Rights for shares of the Common Stock as set forth
below:
- --------------------------------------------------------------------------------------------------------
Number of Rights Subscription Price Per Share Payment
- --------------------------------------------------------------------------------------------------------
Basic Subscription Privilege: ___________ x $2.00 = $____________
(Line 1)
- --------------------------------------------------------------------------------------------------------
Over-Subscription Privilege ___________ x $2.00 = $____________
(Line 2)
- --------------------------------------------------------------------------------------------------------
By exercising the Over-Subscription Privilege, I (we) hereby represent and
certify that I (we) have fully exercised my (our) Basic Subscription Privilege
received in respect of shares of Common Stock held in the below-described
capacity.
Total Payment Required = $________________
(Sum of Lines 1 and 2; must equal total of amounts in Boxes 3 and 4).
BOX 3. [ ] Payment in the following amount is enclosed: _______________
BOX 4. [ ] Please deduct payment from the following account maintained by you as
follows:
____________________ ______________________
Type of Account Account No.
Amount to be deducted: $_________________
Date: _______________, 2002 ______________________________ Signature