Exhibit 99.1
[HERITAGE FINANCIAL LOGO]
STOCK ORDER FORM
PLEASE READ AND COMPLETE THIS STOCK ORDER FORM. INSTRUCTIONS ARE INCLUDED ON
THE REVERSE SIDE OF THIS FORM.
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DEADLINE FOR DELIVERY 10:00 A.M., PACIFIC TIME, ON , 1997
Please mail the Stock Order Form in the enclosed envelope to the address listed
below or hand-deliver to any Heritage Savings Bank office. Heritage Financial
is not required to accept copies of Stock Order Forms.
NUMBER OF SHARES OFFICE USE ONLY
(1) Number of Price Total
Shares per Share Amount Due ------------- ------- -----
[_____________] X $10.00 = [$_____] Date Received Batch # Order
(25 Share Minimum)
METHOD OF PAYMENT PURCHASER INFORMATION
(2) [_] Enclosed is a check or money (4) [_] Check here if you were a
order payable to HERITAGE FINANCIAL Heritage Savings Bank stockholder
CORPORATION for $ . on , 1997.
(3) [_] I authorize Heritage Savings (a) [_] Check here if you are a
Bank to make the withdrawal(s) from Heritage Savings Bank employee, or a
the Heritage Savings Bank account(s) member of the immediate family of a
listed below, and understand that the Heritage Savings employee.
amounts I authorize will not be
available for withdrawal once this (5) Check the box which applies.
Stock Order Form is submitted:
(a) [_] Check here if you were a
ACCOUNT NUMBER(S) AMOUNT(S) Depositor of Heritage Savings Bank
$ on June 30, 1996. List any account(s)
- ------------------------------------- you had on that date below.
$
- ------------------------------------- (b) [_] Check here if you were NOT
$ a depositor at June 30, 1996,
- ------------------------------------- but you were a depositor on
$ September 30, 1997. List any
- ------------------------------------- account(s) you had on that date
Total Withdrawal $ below.
THERE IS NO EARLY WITHDRAWAL PENALTY (c) [_] Check here if you were not
FOR THE PURCHASE OF STOCK. a depositor at either of the above
dates, but were a depositor on
, 1997. List any accounts
you had on that date below.
(d) [_] Check here if you have never
been a Heritage Savings Bank depositor.
ACCOUNT TITLE (NAME(S) ACCOUNT
ON ACCOUNT) NUMBER
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IF ADDITIONAL SPACE IS NEEDED,
PLEASE USE THE BACK OF THIS STOCK
ORDER FORM.
STOCK REGISTRATION (PLEASE PRINT CLEARLY)
(6) (7)
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(First Name) (M.I.) (Last Name) Social Security # or Tax ID#
(stock certificate will show
this number)
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(First Name) (M.I.) (Last Name) Social Security # or Tax ID#
(8)
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(Street Address) (Daytime Phone Number)
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(City) (State) (Zip) (Evening Phone Number)
(9) Form of Stock Ownership (check one)
[_] Individual [_] Joint Tenants [_] Tenants in Common [_] Uniform Transfer to Minors
[_] Individual [_] Corporation [_] Fiduciary (Under [_] Other
Retirement Agreement Dated
Account (IRA) , 199 )
NASD AFFILIATION (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 90 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)
ACKNOWLEDGMENT AND SIGNATURE (VERY IMPORTANT)
I(we) acknowledge receipt of the Prospectus dated , 1997, and I(we) have
read the terms and conditions described therein (including the section
entitled "Risk Factors"). I(we) understand that, after receipt by Heritage
Financial, this order may not be modified or withdrawn without the consent of
Heritage Financial. 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 and I(we) confirm that my(our) order does not conflict with the
purchase limitation and ownership limitation provisions in the Plan of
Conversion. I(we) acknowledge that the common stock being ordered is not a
deposit or savings account, is not federally-insured, and is not guaranteed
by Heritage Financial, or the Washington state government. 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 above 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 Heritage Savings Bank deposit account
requiring more than one signature to withdraw funds. If signing as a
custodian, corporate officer, etc., please include your full title.
STOCK INFORMATION CENTER:
------------------------------------------- Heritage Savings Bank
Signature Title (if applicable) Date 201 5th Ave., S.W.
Olympia, WA 98501
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Signature (if required) Date QUESTIONS? Call (800)
- or (360) -
9:00 am to 4:00 pm,
Monday-Friday
THIS ORDER NOT VALID UNLESS SIGNED
THE SHARES OF COMMON STOCK ARE NOT SAVINGS ACCOUNTS OR SAVINGS DEPOSITS AND ARE
NOT INSURED BY THE FEDERAL DEPOSIT INSURANCE CORPORATION OR ANY OTHER
GOVERNMENT AGENCY.
STOCK ORDER FORM INSTRUCTIONS
1--Indicate the number of shares of Heritage Financial common stock that you
wish to purchase and indicate the amount due. The minimum purchase is 25
shares or $250. The maximum aggregate purchase in the Offering, i.e. the
SUBSCRIPTION, MINORITY STOCKHOLDERS' AND COMMUNITY OFFERING, combined, is
$250,000 for an individual (or persons exercising subscription rights through
a single eligible account at Heritage Savings Bank), together with associates
or group acting in concert. The categories of the Offering are described in
the Prospectus, page . Heritage Financial Corporation reserves the right to
accept or reject orders placed in the Community Offering or Minority
Stockholders Offering. NOTICE TO HERITAGE SAVINGS BANK STOCKHOLDERS: See the
Prospectus, page for the overall limitation on ownership of Heritage
Financial common stock.
2--Payment for shares may be made by check or money order payable to HERITAGE
FINANCIAL CORPORATION. Funds received in this form of payment will be cashed
immediately and deposited into a separate account established for the purposes
of this Offering. You will earn interest at Heritage Savings Bank's passbook
rate from the time funds are received until the Offering is consummated.
3--You may pay for your shares by withdrawal from your Heritage Savings Bank
deposit account(s). Indicate the account number(s) and the amount(s) to be
withdrawn. These funds will be unavailable to you from the time this Stock
Order Form is received until the Offering is consummated. 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 HERITAGE SAVINGS BANK IRA
FUNDS (OR ANY OTHER IRA FUNDS) TO MAKE YOUR STOCK PURCHASE.
4--Please check one or both of these boxes, if applicable.
5--Check the applicable box. THIS INFORMATION IS VERY IMPORTANT BECAUSE
ELIGIBILITY DATES ARE UTILIZED TO PRIORITIZE YOUR ORDER IN THE EVENT THAT WE
RECEIVE MORE STOCK ORDERS THAN AVAILABLE STOCK. List the name(s) on the
deposit account(s) and account number(s) that you held at the applicable date.
Please see the portion of the Prospectus entitled "The Conversion--The
Offerings" for a detailed explanation of how shares will be allocated in the
event the Offering is oversubscribed. Failure to complete this section could
result in a loss of all or part of your stock allocation.
(Continued from previous page)
ACCOUNT TITLE (NAME(S) ON ACCOUNT) ACCOUNT NUMBER
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6--Please 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 Heritage Savings Bank (i)
eligible depositor as of 6/30/96 or (ii) eligible depositor as of 9/30/97 or
depositor or eligible borrower as of /97, you must register the stock in
the name of one of the account holders listed on your account as of the
applicable date. However, adding the name(s) of other persons who are not
account holders, or were account holders at a later 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.
7--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.
8--Be sure to include at least one phone number, in the event you must be
contacted regarding this Stock Order Form.
9--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 Heritage Financial 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 the
TRANSFER Uniform Transfers to Minors laws of individual states. There may
TO MINORS: 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 WA
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FIDUCIARIES:Stock held in a fiduciary capacity must contain the following:
1. The name(s) of the fiduciary:
--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