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EXHIBIT 99.1
ENROLLMENT FORM
LNBB DIRECT
ENROLLMENT FORM
PLEASE READ CAREFULLY BEFORE SIGNING
Status: (please check one and sign below)
[ ] I hereby represent and confirm that I am the registered holder of common
shares of LNB Bancorp.
[ ] I have checked the box below for "Optional Cash Payment" and have
enclosed a check or money order in an amount of at least $250.00 to make
an initial purchase of LNB Bancorp common shares and to become a
registered holder of common shares of LNB Bancorp.
Check here if mailing information below is how you want your stock
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SHAREHOLDER'S NAME(S) AND ADDRESS APPEARS HERE IN AN ADDRESS BOX
If the above is not how you want your stock registered, please print or type the
correct account registration below. (Note: All parties named in the account
registration must sign the Enrollment Form in the space provided on the
reverse.)
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Social Security Account Number (SSAN)
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INDIVIDUAL OR JOINT. Joint accounts will be presumed to be joint tenants unless
restricted by applicable state law or otherwise indicated.
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Owner's First Name M.I. Last Name Owner's Social Security Number
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Joint Owner's First Name M.I. Last Name
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CUSTODIAL. A minor is the beneficial owner of the account with an adult
Custodian managing the account until the minor becomes of age, as specified in
the Uniform Gifts/Transfers to Minors Act in the minor's state of residence.
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Custodian's First Name M.I. Last Name
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Minor's First M.I. Last Minor's Social Minor's State
Name Name Security Number of Residence
TRUST. Account is established in accordance with provisions of a trust
agreement.
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Trustee Name Name of Trust
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Trust Date Tax ID Number Beneficiary
Dividend Reinvestment Options: (please check one and sign below)
IF YOU CURRENTLY PARTICIPATE IN THE LNB BANCORP DIVIDEND REINVESTMENT
PLAN AND WANT YOUR EXISTING INSTRUCTIONS ABOUT REINVESTMENT OF
DIVIDENDS TO CONTINUE TO APPLY, YOU NEED NOT CHECK ANY BOX.
[ ] Full Dividend Reinvestment: I hereby authorize LNB Bancorp to pay to
Registrar and Transfer Company, as agent for my account, all cash
dividends due to me on common shares of LNB Bancorp for which I am the
registered holder. I want to reinvest dividends on all shares
registered in my name for the purchase of full or fractional common
shares of LNB Bancorp in accordance with the terms of LNBB Direct, as
may be amended from time to time (the "Plan").
[ ] Partial Dividend Reinvestment: I hereby authorize LNB Bancorp to pay
to Registrar and Transfer Company, as agent for my account, all cash
dividends due to me on (pick one) [ ] common shares of LNB
Bancorp; or [ ] % of LNB Bancorp common shares for which I am the
registered holder. I want to reinvest dividends on the indicated number
of shares or percentage of shares as so indicated in my name for the
purchase of full or fractional shares of LNB Bancorp common shares in
accordance with the terms of the Plan.
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[ ] Optional Cash Purchase Only: I want to receive cash dividends for all
shares registered in my name and participate in the cash purchase
option only. (I understand that I will receive full dividend
reinvestment on the shares held by the Plan Administrator in book entry
form on my behalf.)
Cash Purchase Options: (please check all that apply and sign below)
[ ] Optional Cash Payment: I enclose herewith a check or money order
payable to LNBB Direct in the sum of $ (minimum $250.00) and
hereby authorize Registrar and Transfer Company, as my agent, to invest
the entire proceeds from that check or money order in full or
fractional shares of LNB Bancorp common shares in accordance with the
terms of the Plan.
[ ] Optional Automatic Investment: I hereby authorize Registrar and
Transfer Company, as agent, to debit my checking, savings or other
account $ on a monthly basis as set forth in the completed
automatic debit authorization form on the reverse side and invest such
designated amount in full or fractional shares of LNB Bancorp common
shares in accordance with the terms of the Plan. The reverse side must
be completed. All withdrawals will be made on or about the 20th of each
month.
I hereby appoint Registrar and Transfer Company as my agent under the terms and
conditions of LNBB Direct, as described in the Prospectus accompanying this
Enrollment Form, to receive any cash dividends that may become payable to me on
any of the common shares of LNB Bancorp as specified above, and to apply such
dividends to the purchase of shares as provided in the Plan. I acknowledge
receipt of the LNBB Direct Prospectus and agree to the terms and conditions of
the Plan stated in that Prospectus, as same may be amended from time to time.
I understand that I may change my reinvestment options or revoke this
authorization at any time by notifying Registrar and Transfer Company in writing
of my desire to modify or terminate my participation in LNBB Direct. I
understand that the purchase of common shares will be made subject to the terms
and conditions of the Plan, and that I may terminate this authorization at any
time by notifying Registrar and Transfer Company in writing.
ENROLLMENT SIGNATURES
Return this Enrollment Form only if you wish to participate in LNBB Direct. This
Enrollment form, when signed, should be mailed to: LNBB Direct, c/o Registrar
and Transfer Company, Direct Purchase/DRP Department, 10 Commerce Drive,
Cranford, New Jersey 070167-3572.
By signing this form, I request enrollment, certify that I have received and
read the prospectus describing the Dividend Reinvestment and Direct Purchase
Plan for LNB Bancorp, Inc. common shares and agree to abide by the Terms and
Conditions of the Plan. I hereby appoint Registrar and Transfer Company as my
agent to apply dividends and any investments I may make to the purchase of
shares under the Plan. I understand that I may revoke this authorization at any
time by written notice to Registrar and Transfer Company.
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Substitute Form W-9:
Under penalties of perjury, I also certify that:
1. The number shown on this form is my/our correct Social Security Number or
Taxpayer ID Number.
2. I (we) am not subject to backup withholding either because (a) I am exempt
from backup withholding, or (b) I have not been notified by the Internal
Revenue Service ("IRS") that I am subject to backup withholding as a result
of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding.
All owners of shares held in joint registration must sign this Enrollment Form.
DATE:
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Shareholder Signature Joint Shareholder Signature
(if jointly held)
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Social Security Account Number Social Security Account Number
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State or country (if other than the State or country (if other than the
United States) of residence United States) of residence if
jointly held
Daytime Phone ( )
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AUTOMATIC DEBIT AUTHORIZATION
You may authorize automatic monthly deductions from your personal bank account.
Registrar and Transfer Company will automatically debit your bank account on or
about the 20th of each month and invest these deductions in LNB Bancorp Common
Stock. Please indicate the account from which you would like your additional
investments withdrawn. You must enclose a pre-encoded deposit ticket or blank,
voided check to help us identify your account or designate your account number
and the name of the financial institution where you maintain your account in the
space provided below.
Amount to be deducted:
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(must be for at least $50 and cannot exceed $2,500 per month)
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Signature Date Signature
[ ] Checking account [ ] Savings account [ ] Other account
Acct. No. Acct. No. Acct. No.
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Financial Institution
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AUTOMATIC CREDIT AUTHORIZATION
[PLEASE NOTE THAT THIS SERVICE WILL NOT BE AVAILABLE TO YOU IF YOU HAVE ELECTED
EITHER FULL DIVIDEND REINVESTMENT OR PARTIAL DIVIDEND REINVESTMENT.]
You may authorize the automatic crediting of quarterly cash dividends to your
checking or savings account. Please indicate the account which you would like
your quarterly cash dividends credited. You must enclose a pre-encoded deposit
ticket or blank, voided check to help us identify your account or designate your
account number and the name of the financial institution where you maintain your
account in the space provided below.
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Signature Date Signature
[ ] Checking account [ ] Savings account [ ] Other account
Acct. No. Acct. No. Acct. No.
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Financial Institution
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