EXHIBIT 99.4
STOCK ORDER FORM & Montgomery Financial Corporation
CERTIFICATION FORM (Proposed Holding Company for Montgomery Savings)
Note: Please read the Stock Order Form Guide and Instructions on the back of
this form before completion.
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Deadline
The Subscription Offering ends at Noon, Crawfordsville, Indiana, Time, on XXXXX
XX, 1997. Your Stock Order Form and Certification Form, properly executed and
with the correct payment, must be received at the address on the bottom of this
form by this deadline, or it will be considered void.
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Number of Shares
(1) Number of Shares Price Per Share (2) Total Amount Due
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X $10.00 =
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The minimum number of shares that may be subscribed for is 25. The maximum
individual subscription, when combined with exchange shares, is 20,000 shares in
the Subscription and Community Offering.
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Method of Payment
(3) [ ] Enclosed is a check, bank draft or money order payable to Montgomery
Financial Corporation for $___________ (or cash if presented in person).
(4) [ ] I authorize Montgomery Savings to make withdrawals from my Montgomery
Savings account(s) shown below, and understand that the amounts will not
otherwise be available for withdrawal:
Account Number(s) Amount(s)
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Total Withdrawal
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Purchaser Information
(5) [ ] Check here if you are a director, officer or employee of Montgomery
Savings or a member of such person's immediate family.
[ ] Check here if you are a depositor or a borrower and enter below
information for all accounts you had at the Eligibility Record Date
(September 30, 1995), Supplemental Eligibility Record Date (March 31,
1997) or the Voting Record Date (XXX, 1997). If additional space is
needed, please utilize the back of this form. Please confirm account(s)
by initialing here. ______________
Account Title (Names on Accounts) Account Number
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(6) Stock Registration
[ ] Individual [ ] Corporation
[ ] Joint Tenants [ ] Partnership
[ ] Tenants in Common [ ] Individual Retirement Account
[ ] Uniform Transfer to Minors [ ] Fiduciary/Trust (Under
[ ] Uniform Gift to Minors Agreement Dated______________)
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Name Social Security or Tax I.D.
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Name Daytime Telephone
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Street Address Evening Telephone
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City State Zip Code County of Residence
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NASD Affiliation (This section only applies to those individuals who meet the
delineated criteria)
[ ] Check here if you are a member of the National Association of Securities
Dealers, Inc. ("NASD"), a person associated with an NASD member, a member of the
immediate family of any such person to whose support such person contributes,
directly or indirectly, or the holder of an account in which an NASD member or
person associated with an NASD member has a beneficial interest. To comply with
conditions under which an exemption from the NASD's Interpretation With Respect
to Free-Riding and Withholding is available, you agree, if you have checked the
NASD affiliation box: (1) not to sell, transfer or hypothecate the stock for a
period of three months following the issuance and (2) to report this
subscription in writing to the applicable NASD member within one day of the
payment therefor.
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Acknowledgment By signing below, I acknowledge receipt of the Prospectus dated
XXXX, 1997 and understand I may not change or revoke my order once it is
received by Montgomery Financial Corporation. I also certify that this stock
order is for my account and there is no agreement or understanding regarding any
further sale or transfer of these shares. Federal regulations prohibit any
persons from transferring, or entering into any agreement directly or indirectly
to transfer, the legal or beneficial ownership of conversion subscription rights
or the underlying securities to the account of another person. Montgomery
Savings will pursue any and all legal and equitable remedies in the event it
becomes aware of the transfer of subscription rights and will not honor orders
known by it to involve such transfer. Under penalties of perjury, I further
certify that: (1) the social security number or taxpayer identification number
given above is correct; and (2) I am not subject to backup withholding. You must
cross out this item, (2) above, if you have been notified by the Internal
Revenue Service that you are subject to backup withholding because of
under-reporting interest or dividends on your tax return. By signing below, I
also acknowledge that I have not waived any rights under the Securities Act of
1933 and the Securities Exchange Act of 1934.
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Signature Sign and date this form. When purchasing as a custodian, corporate
officer, etc., include your full title. An additional signature is required only
if payment is by withdrawal from an account that requires more than one
signature to withdraw funds. YOUR ORDER WILL BE FILLED IN ACCORDANCE WITH THE
PROVISIONS OF THE PROSPECTUS. THIS ORDER IS NOT VALID IF THE STOCK ORDER FORM
AND CERTIFICATION FORM ARE NOT BOTH SIGNED. If you need help completing this
Form, you may call the Stock Information Center at (XXX) XXX-XXXX.
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Signature Title (if applicable) Date
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Signature Title (if applicable) Date
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THE SHARES OF COMMON STOCK OFFERED HEREBY ARE NOT SAVINGS ACCOUNTS AND ARE NOT
INSURED OR GUARANTEED BY THE FEDERAL DEPOSIT INSURANCE CORPORATION, THE SAVINGS
ASSOCIATION INSURANCE FUND OR ANY OTHER GOVERNMENTAL AGENCY.
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Date Rec'd ___/___/___ Order # ____________ Batch # ____________
OFFICE USE Check # ______________ Category ____________
Amount $______________ Initials ____________
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STOCK INFORMATION CENTER
119 E. Main Street
Crawfordsville, Indiana 47933
(XXX) XXX-XXXX
Stock Ownership Guide
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Individual - The Stock is to be registered in an individual's name only. You may
not list beneficiaries for this ownership.
Joint Tenants - Joint tenants with right of survivorship identifies two or more
owners. When stock is held by joint tenants with rights of survivorship,
ownership automatically passes to the surviving joint tenant(s) upon the death
of any joint tenant. You may not list beneficiaries for this ownership.
Tenants in Common - Tenants in common may also identify two or more owners. When
stock is to be held by tenants 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 the deceased co-tenant. All parties must agree to the transfer or
sale of shares held by tenants in common. You may not list beneficiaries for
this ownership.
Individual Retirement Account - Individual Retirement Account ("IRA") holders
may make stock purchases from their deposits through a prearranged
"trustee-to-trustee" transfer. Stock may only be held in a self-directed IRA.
The Montgomery Savings does not offer a self-directed IRA. Please contact the
Stock Information Center if you have any questions about your IRA account. There
will be no early withdrawal or IRS penalties incurred by these transactions.
Uniform Gift to Minors - For residents of many states, stock may be held in the
name of a custodian for the benefit of a minor under the Uniform Transfer to
Minors Act. For residents in other states, stock may be held in a similar type
of ownership under the Uniform Gift 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 child reaches legal
age.
Instructions: See your legal advisor if you are unsure about the correct
registration of your stock.
On the first 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.
Corporation/Partnership - Corporations/Partnerships may purchase stock. Please
provide the Corporation/Partnership's legal name and Tax I.D. To have depositor
rights, the Corporation/Partnership must have an account in the legal name.
Please contact the Stock Information Center to verify depositor rights and
purchase limitations.
Fiduciary/Trust - Generally, fiduciary relationships (such as Trusts, Estates,
Guardianships, etc.) are established under a form of trust agreement or 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 trustee, executor, 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 type of legal
document establishing the fiduciary relationship (agreement, court order, etc.).
In the blank after "Under Agreement Dated", fill in the date of the document
governing the relationship. The date of the document need not be provided for a
trust created by a will.
An example of a fiduciary ownership of stock in the case of a trust is: John D.
Smith, Trustee for Thomas A. Smith Under Agreement Dated 06/09/97.
Definition of Associate
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The term "associate" of a person is defined to mean (i) any corporation or other
organization (other than Montgomery Financial Corporation ("Holding Company"),
the Bank, or a majority owned subsidiary of the Bank) of which such person is a
director, officer or partner or is directly or indirectly the beneficial owner
of 10% or more of any class of equity securities; (ii) any trust or other estate
in which such person has a substantial beneficial interest or as to which such
person serves as trustee or in a similar fiduciary capacity, provided, however,
that such term shall not include any tax-qualified employee stock benefit plan
of the Holding Company or the Bank in which such person has a substantial
beneficial interest or serves as a trustee or in a similar fiduciary capacity;
and (iii) any relative or spouse of such person, or any relative of such person,
who either has the same home as such person or who is a director or officer of
the Holding Company or the Bank or any of their subsidiaries.
Item Instruction
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Items 1 and 2 - Fill in the number of shares that you wish to purchase and the
total payment due. The amount due is determined by multiplying the number of
shares by the subscription price of $10.00 per share. The minimum purchase is 25
shares. The maximum individual subscription, when combined with exchange, is
20,000 shares in the Subscription Community Offering.
Montgomery Financial Corporation has reserved the right to reject the
subscription of any order received in the Public Offering, if any, in whole or
in part.
Item 3 - Payment for shares may be made in cash (only if delivered by you in
person) by check, bank draft or money order made payable to Montgomery Financial
Corporation. DO NOT MAIL CASH. If you choose to make a cash payment, take your
Stock Order Form, signed Certification Form and payment in person to Montgomery
Savings. Your funds will earn interest at Montgomery Saving's current passbook.
Item 4 - To pay by withdrawal from a savings account or certificate at
Montgomery Savings, insert the account number(s) and the amount(s) you wish to
withdraw from each account. If more than one signature is required to withdraw,
each must sign in the Signature box on the front of this form. To withdraw from
an account with checking privileges, please write a check. No early withdrawal
penalty will be charged on funds used to purchase stock. A hold will be placed
on the account(s) for the amount(s) you show. Payments will remain in
certificate account(s) until the stock offering closes. However, if a partial
withdrawal reduces the balance of a certificate account to less than the
applicable minimum, the remaining balance will thereafter earn interest at the
passbook rate.
Item 5 - Please check this box if you were a depositor on the Eligibility Record
Date (September 30, 1995), and/or a depositor on the Supplemental Eligibility
Record Date (March 31, 1997) or a depositor on the Voting Record Date (Xxxxx XX,
1997) and list all names on the account(s) and all account number(s) of those
accounts you had at these dates to ensure proper identification of your purchase
rights.
Items 6 - The stock transfer industry has developed a uniform system of
shareholder registrations that we will use in the issuance of Hemlock Federal
Financial Corporation common stock. Print the name(s) in which you want the
stock registered and the mailing address of the registration. Include the first
name, middle initial and last name of the shareholder. Avoid the use of two
initials. Please omit words that do not affect ownership rights, such as "Mrs.",
"Mr.", "Dr.", "special account", etc.
Subscription rights are not transferable. If you are a qualified member, to
protect your priority over other purchasers as described in the Prospectus, you
must take ownership in at least one of the account holder's names.
Enter the Social Security or Tax I.D. number of one registered owner. This
registered owner must be listed on the first "NAME" line. Be sure to include
your telephone number because we will need to contact you if we cannot execute
your order as given. Review the Stock Ownership Guide on this page and refer to
the instructions for Uniform Gift to Minors/Uniform Transfer to Minors and
Fiduciaries.
Account Title (Names on Accounts) Account Number
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