EXHIBIT 99.6
PROVIDENT BANCORP, INC.
STOCK ORDER FORM
PLEASE READ AND COMPLETE THIS STOCK ORDER FORM.
INSTRUCTIONS ARE INCLUDED [ON THE REVERSE SIDE OF THIS FORM].
DEADLINE FOR DELIVERY FOR OFFICE USE ONLY
10:00 A.M., NEW YORK TIME, ON , 1998
Please mail the completed Stock Date Rec'd Batch # Order # Deposit
Order Form in the enclosed reply
envelope or hand-deliver to any
Provident Bank office. COPIES AND
FACSIMILES OF STOCK ORDER FORMS
MAY NOT BE ACCEPTED.
(1) NUMBER OF SHARES
NUMBER OF SHARES PRICE PER SHARE TOTAL AMOUNT DUE
X =
$10.00 $
(25 Share Minimum)
(3) PURCHASER INFORMATION
(2) METHOD OF PAYMENT (WIRES WILL NOT BE ACCEPTED)
[_] Check here if you are a Provident
Bank Officer, director or employee.
[_]Enclosed is a check or money CHECK THE ONE BOX WHICH APPLIES:
order payable to PROVIDENT
BANK for $ .
(a)[_] Eligible Account Holder--Check
[_]I authorize Provident Bank here if you were a depositor with an
to withdraw from the aggregate of at least $50 at Provident
PROVIDENT BANK passbook or Bank on DECEMBER 31, 1996. List below
certificate account(s) any account(s) you had at that date.
listed below, and I (b)[_] Supplemental Eligible Account
understand that the amounts Holder--Check here if you were a
I authorize below will not depositor with an aggregate of at
otherwise be available to me least $50 at Provident Bank on
once this Stock Order Form SEPTEMBER 30, 1998, but are not an
is submitted. (THERE WILL BE Eligible Account Holder. List below
NO EARLY WITHDRAWAL PENALTY any account(s) you had September 30,
FOR THE PURCHASE OF STOCK.) 1998.
(c)[_] Other Member--Check here if you
were a depositor of Provident Bank on
, 1998, OR were a borrower at that
date whose loan was outstanding at
July 9, 1998, but you are NOT an
Eligible or Supplemental Eligible
Account Holder.
ACCOUNT NUMBER(S) AMOUNT(S)
--------------- $ (d)[_] The preceding boxes do not apply
--------------- $ to you.
--------------- $
ACCOUNT TITLE (NAME(S) ON THE ELIGIBILITY
DATE)
--------------- $ ACCOUNT
NUMBER(S)
--------------- $
TOTAL WITHDRAWAL: $ ------------------------ ----------------
------------------------ ----------------
(4) STOCK REGISTRATION (PLEASE PRINT CLEARLY) THE REGISTRATION INFORMATION YOU
LIST BELOW WILL BE UTILIZED FOR SUBSEQUENT MAILINGS, INCLUDING THE
REGISTRATION OF STOCK CERTIFICATES. PLEASE MAKE SURE THE INFORMATION IS
COMPLETE AND LEGIBLE. IF REGISTERING SHARES IN MORE THAN ONE NAME, LIST THE
NAME AND ADDRESS OF THE FIRST PERSON NAMED.
NOT LISTING ALL APPLICABLE ACCOUNTS COULD
RESULT IN A LOSS OF ALL OR PART OF YOUR
STOCK ALLOCATION. IF ADDITIONAL SPACE IS
NEEDED, PLEASE ATTACH A SEPARATE PAGE.
------------------------ ----------------
(First Name, Middle Initial, Last Name)
Social Security #/Tax ID# (certificate
will show this number)
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(First Name, Middle Initial, Last Name)
Social Security #/Tax ID#
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(Street Address) (Daytime Phone Number)
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(City, State, Zip Code) (Evening Phone Number)
(5) FORM OF STOCK OWNERSHIP (CHECK ONE--SEE [REVERSE SIDE] OF THIS FORM FOR
OWNERSHIP DEFINITIONS)
[_] Individual [_] Joint Tenants
[_] Tenants in Common [_] Uniform
[_] IRA (for broker use only) Transfer to
[_] Corporation Minors
[_] Fiduciary (Under Agreement Dated ,
19 )
[_] Other
(6) NASD AFFILIATION (CHECK AND INITIAL ONLY IF APPLICABLE.)
[_] Check here and initial below if you are a member of the NASD ("National
Association of Securities Dealers") 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 three months days following issuance; and (ii) to
report this subscription in writing to the applicable NASD member I am
associated with within one day of payment for the stock. (Please initial)
(7) ACKNOWLEDGMENT AND SIGNATURE (VERY IMPORTANT)
I(we) acknowledge receipt of the Prospectus dated , 1998, and that I(we)
have been advised to read the Prospectus (including the section entitled
"Risk Factors"). I(we) understand that, after receipt by Provident Bancorp,
Inc., this order may not be modified or withdrawn without the consent of
Provident Bancorp, Inc. I(we) hereby certify that the shares which are being
subscribed for are for my(our) account only, and that I(we) have no present
agreement or understanding regarding any subsequent sale or transfer of such
shares or any applicable subscription rights and I(we) confirm that my(our)
order does not conflict with the purchase limitations in the Plan of
Reorganization. I(we) acknowledge that the common stock being ordered is not
a deposit or savings account, is not insured by the FDIC and is not
guaranteed by Provident Bancorp, Inc. or any government agency. Under
penalties of perjury, I(we) certify that (1) the Social Security #(s) or Tax
ID#(s) given above is(are) correct; and (2) I(we) am(are) not subject to
backup withholding tax. (You must cross out #2 if you have been notified by
the Internal Revenue Service that you are subject to backup withholding
because of underreporting interest or dividends on your tax return).
PLEASE SIGN AND DATE THIS FORM. ONLY ONE SIGNATURE IS REQUIRED, UNLESS
AUTHORIZING A WITHDRAWAL FROM A PROVIDENT BANK DEPOSIT ACCOUNT REQUIRING MORE
THAN ONE SIGNATURE TO WITHDRAW FUNDS. IF SIGNING AS A CUSTODIAN, CORPORATE
OFFICER, ETC., PLEASE INCLUDE YOUR FULL TITLE.
- -------------------------------------- ---------------------------------------
Signature Title (if applicable) Date Signature Title (if applicable) Date
THIS ORDER IS NOT VALID UNLESS SIGNED--WE RECOMMEND RETAINING A COPY OF THIS
FORM FOR YOUR RECORDS
QUESTIONS? PLEASE CALL (914) - , FROM 9:00 AM TO 4:00 PM, MONDAY-FRIDAY
STOCK INFORMATION CENTER: PROVIDENT BANK, 400 RELLA BLVD.,
MONTEBELLO, NY 10901
STOCK ORDER FORM INSTRUCTIONS
(1) NUMBER OF SHARES -- Indicate the number of shares of Provident Bancorp,
Inc. common stock that you wish to purchase, and indicate the amount due. The
minimum purchase is 25 shares or $250. No person may purchase in the
Subscription Offering more than $200,000 of stock. No person, together with
associates or persons acting in concert with such person, may purchase more
than an aggregate of $400,000 of stock in all categories of the Offering,
consisting of the Subscription Offering and any Community Offering and/or
Syndicated Community Offering. The categories of the Offering are described in
the Prospectus section entitled "The Reorganization and Offering." Provident
Bancorp, Inc. reserves the right to accept or reject orders, in whole or in
part, placed in any Community Offering and Syndicated Community Offering.
Note: Subscription rights to purchase stock in the Subscription Offering are
non-transferable and expire at the conclusion of the Subscription Offering.
(2) METHOD OF PAYMENT -- Payment for shares may be made by check or money
order payable to PROVIDENT BANK. Funds received in this form of payment will
be cashed immediately. You will earn interest at Provident Bank's passbook
rate from the time funds are received until the Offering is consummated.
You may pay for shares by withdrawal from your existing Provident Bank
passbook or certificate account(s). You may NOT authorize withdrawal from
transaction accounts (i.e. checking, money market). Indicate the account
number(s) and the amount(s) to be withdrawn. Funds designated will be
unavailable to you from the time this Stock Order Form is received, however,
the funds will continue to earn interest at the account's contractual rate
until the Offering is consummated.
PLEASE CONTACT THE STOCK INFORMATION CENTER EARLY IN THE OFFERING PERIOD IF
YOU ARE INTENDING TO UTILIZE PROVIDENT BANK IRA FUNDS (OR ANY OTHER IRA FUNDS)
TO MAKE YOUR STOCK PURCHASE.
(3) PURCHASER INFORMATION -- This information is very important because
eligibility dates are utilized to prioritize your order in the event that we
receive orders for more stock than is available. Please see the portion of the
Prospectus entitled "The Reorganization and Offering" for explanation of
purchase priorities and a detailed explanation of how shares will be allocated
in the event the Offering is oversubscribed. FAILURE TO COMPLETE THIS SECTION,
COMPLETING THIS SECTION INCORRECTLY OR OMITTING INFORMATION IN THIS SECTION
COULD RESULT IN A LOSS OF ALL OR PART OF YOUR STOCK ALLOCATION.
(4) STOCK REGISTRATION -- CLEARLY PRINT the name(s) and address in which you
want the stock certificate registered and mailed. If you are exercising
subscription rights by purchasing in the Subscription Offering as a Provident
Bank (i) Eligible Account Holder as of 12/31/96 or (ii) Supplemental Eligible
Account Holder as of 9/30/98 or (iii) Other Member as of / /98, you must
register the stock in the name of at least one of the account holders listed
on the account as of the applicable date. However, adding the name(s) of other
persons who are not account holders, or were account holders only at a later
eligibility date than yourself, will be a violation of your subscription right
and will result in a loss of your purchase priority. NOTE: ONE STOCK
CERTIFICATE WILL BE GENERATED PER ORDER FORM. IF VARIOUS REGISTRATIONS AND
SHARE AMOUNTS ARE DESIRED ON VARIOUS CERTIFICATES, A SEPARATE STOCK ORDER FORM
MUST BE COMPLETED FOR EACH CERTIFICATE DESIRED. Purchase limitations apply to
aggregate purchases.
Enter the Social Security Number or Tax ID Number of the registered owner(s).
The first number listed will be identified with the stock certificate for tax
purposes. Be sure to include at least one phone number, in the event you must
be contacted regarding this Stock Order Form.
(5) FORM OF STOCK OWNERSHIP -- Please check the one type of ownership
applicable to your registration. An explanation of each follows:
GUIDELINES FOR REGISTERING STOCK
For reasons of clarity and standardization, the stock transfer industry has
developed uniform stockholder registrations which we will utilize in the
issuance of your Provident Bancorp, Inc. stock certificate(s). If you have
any questions, please consult your legal advisor.
Stock ownership must be registered in one of the following manners:
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INDIVIDUAL: Avoid the use of two initials. Include the first given name,
middle initial and last name of the stockholder. Omit words of
limitation that do not affect ownership rights such as
"special account," "single man," "personal property," etc. If
the stock is held individually upon the individual's death,
the stock will be owned by the individual's estate and
distributed as indicated by the individual's will or otherwise
in accordance with law.
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JOINT: Joint ownership of stock by two or more persons shall be
inscribed on the certificate with one of the following types
of joint ownership. Names should be joined by "and"; do not
connect with "or." Omit titles such as "Mrs.," "Dr.," etc.
JOINT TENANTS--Joint Tenancy with Right of Survivorship and
not as Tenants in Common may be specified to identify two or
more owners where ownership is intended to pass automatically
to the surviving tenant(s). TENANTS IN COMMON--Tenants in
Common may be specified to identify two or more owners. When
stock is held as tenancy in common, upon the death of one co-
tenant, ownership of the stock will be held by the surviving
co-tenant(s) and by the heirs of the deceased co-tenant. All
parties must agree to the transfer or sale of shares held in
this form of ownership.
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UNIFORM Stock may be held in the name of a custodian for a minor under
TRANSFER TO the Uniform Transfers to Minors laws of the individual states.
MINORS: There may be only one custodian and one minor designated on a
stock certificate. The standard abbreviation of custodian is
"CUST,", while the description "Uniform Transfers to Minors
Act" is abbreviated "UNIF TRAN MIN ACT." Standard U.S. Postal
Service state abbreviations should be used to describe the
appropriate state. For example, stock held by John P. Jones
under the Uniform Transfers to Minors Act will be abbreviated:
JOHN P. JONES CUST SUSAN A. JONES
UNIF TRAN MIN ACT NY
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FIDUCIARIES: Stock held in a fiduciary capacity must contain the following:
1. The name(s) of the fiduciary(ies):
--If an individual, list the first given name, middle
initial and last name.
--If a corporation, list the corporate title
--If an individual and a corporation, list the
corporation's title before the individual.
2. The fiduciary capacity:
--Administrator, Conservator, Committee, Executor,
Trustee, Personal Representative, Custodian
3. The type of document governing the fiduciary relationship.
Generally, such relationships are either under a form of
living trust agreement or pursuant to a court order.
Without a document establishing a fiduciary relationship,
your stock may not be registered in a fiduciary capacity.
4. The date of the document governing the relationship. The
date of the document need not be used in the description of
a trust created by a will.
5. Either of the following:
The name of the maker, donor or testator
OR
The name of the beneficiary
Example of Fiduciary Ownership:
JOHN D. SMITH, TRUSTEE FOR TOM A. SMITH
UNDER AGREEMENT DATED 6/9/74
(6) NASD AFFILIATION -- Check the box and initial, if applicable.
(7) ACKNOWLEDGMENT AND SIGNATURE -- Stock order forms submitted without a
signature will not be accepted. Only one signature is required, unless the
method of payment section of this Form includes authorization to withdraw from
a Provident Bank account requiring more than one signature. If signing as a
custodian, trustee, corporate officer, etc., please include your title. If
exercising a Power of Attorney, you must submit a copy of the POA agreement
with this Form.
QUESTIONS? Please call the Stock Information Center at (914) - , from
9:00 a.m. to 4:00 p.m., Monday through Friday.
THE SHARES OF COMMON STOCK ARE NOT DEPOSIT ACCOUNTS AND ARE NOT INSURED BY THE
FEDERAL DEPOSIT INSURANCE CORPORATION OR ANY OTHER GOVERNMENT AGENCY.