EX. 99.6
[H/C Logo]
Stock Center
Atlantic Coast Federal
505 Haines Avenue
Waycross, GA 31501
866-579-9631
Stock Order Form & Certification Form Note: Please read the Stock Order Form
Instructions and Guide before completing this form.
Deadline: The Subscription Offering expires at 12:00 Noon, Eastern Time on
Friday, June xx, 2004. Your Stock Order and Certification Form, properly
executed and with the correct payment, must be received at the Stock Center or a
branch of Atlantic Coast Federal by this deadline, or your subscription rights
will be considered void. No photocopied or faxed Order Forms will be accepted.
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Number of Shares / Amount of Payment
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(1) Number of Shares to purchase Price Per Share (2) Total Amount Due
X $10.00 = $
(minimum 25)
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Purchase Limitations The minimum number of shares for which you may subscribe
is 25. The maximum purchase limitation for any person or persons ordering
through a single account or persons acting in concert in the Subscription
Offering is 50,000 shares or $500,000.
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Method of Payment
(3) [] Enclosed is a check, bank draft, or money order made payable to
Atlantic Coast Federal Corporation for $________________.
(4) [] I authorize Atlantic Coast Federal Corporation to make the withdrawals
from my Atlantic Coast Federal account(s) shown below, and understand
that the amounts will not otherwise be available for withdrawal:
Account Number(s) Amount(s)
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$
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Total Withdrawal $
There is no penalty for early withdrawals used for this payment.
To withdraw from an account with checking privileges, please write a check.
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Purchaser Information
(5) [] Check here if you were a depositor with at least $50.00 on deposit at
December 31, 2002 and/or at March 31, 2004. List all the names on the
account(s) and all the account number(s) of those accounts you had at
these dates to ensure proper identification of your purchase rights.
Confirm account(s) by initialing here________.
Account Title (Names on Accounts) Account Number
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[] Check here if you are a director, officer or employee of Atlantic Coast
Federal or a member of such person's immediate family.
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(6) Stock Registration Form of stock ownership
[] Individual [] Uniform Transfer to Minors [] Partnership
[] Joint Tenants (WROS) [] Uniform Gift to Minors [] Individual Retirement Account
[] Tenants in Common [] Corporation [] Fiduciary/Trust (Under Agreement Dated __________)
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(7) 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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[] (8) NASD Affiliation (This section 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 You agree, if you have checked the NASD affiliation box to report
this subscription in writing to the applicable NASD member within one day of the
payment therefor.
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(9) [] Associate- Acting in concert Check here, and complete the reverse side of
this form, if you or any associates (as defined on the reverse side of this
form) or persons acting in concert with you have submitted other orders for
shares in the offerings.
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Acknowledgement By signing below, I acknowledge receipt of the Prospectus dated
May xx, 2004 and the provisions therein and understand that I may not change or
revoke my order once it is received by Atlantic Coast Federal Corporation. Under
penalties of perjury, the undersigned certifies that they are purchasing shares
solely for their account and that there is no agreement or understanding
regarding the sale or transfer of such shares, or their right to subscribe for
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. Atlantic Coast Federal Corporation 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 underreporting interest or dividends on your tax
return.
(10) Signature Sign and date the form. When purchasing as a custodian, corporate
officer, etc., include your full title. An additional signature is required only
when payment is by withdrawal from an account that requires more than one
signature to withdraw funds.
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Authorized Signature Title (if applicable) Date
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(11) Certification Form Be sure to sign the Certification Form on the reverse
side.
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Authorized Signature Title (if applicable) Date
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YOUR ORDER WILL BE FILLED IN ACCORDANCE WITH THE PROVISIONS OF THE PROSPECTUS.
THIS ORDER IS NOT VALID IF NOT SIGNED. If you need help completing this Form,
you may call the Stock Center at (800) xxx-xxxx.
THE SHARES OF COMMON STOCK OFFERED HEREBY ARE NOT SAVINGS ACCOUNTS, ARE NOT AN
OBLIGATION OF OR GUARANTEED BY ATLANTICCOAST FEDERAL, AND ARE NOT INSURED BY THE
FEDERAL DEPOSIT INSURANCE CORPORATION OR ANY OTHER GOVERNMENTAL AGENCY. THESE
SECURITIES ARE SUBJECT TO INVESTMENT RISK AND MAY LOSE VALUE.
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FOR OFFICE USE ONLY
Date Rec'd ___/___/___ Check # __________ Amount $________ Category ____ Batch # _____ Order #_______ Initials ______
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BE SURE TO SIGN THE CERTIFICATION FORM ON THE REVERSE SIDE------->
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[Atlantic Coast Federal Logo]
Item (5) -(continued)
Account Title (Names on Account) Account Number
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Account Title (Names on Account) Account Number
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Item (9) - (continued)
List below all other orders submitted by you or your Associates (as defined) or
by persons acting in concert with you.
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The term "associate," when used to indicate a relationship with any person., is
defined to mean (i) a corporation or organization (other than Atlantic Coast
Federal Corporation, Atlantic Coast MHC or Atlantic Coast Federal) 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 capacity, provided,
however, that such term shall not include any tax qualified employee stock
benefit plan of Atlantic Coast Federal Corporation, Atlantic Coast MHC or
Atlantic Coast Federal in which such person has a substantial beneficial
interest or serves as a director or in a similar fiduciary capacity, and (iii)
any relative or spouse of such person, or any relative of such spouse, who has
the same home as such person or who is a director or officer of Atlantic Coast
Federal Corporation, Atlantic Coast MHC or Atlantic Coast Federal
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CERTIFICATION FORM
(This form must be dated and signed along with your dated and signed
Stock Order Form on the reverse side.)
I ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT OR ACCOUNT AND IS NOT
FEDERALLY INSURED AND IS NOT GUARANTEED BY ATLANTIC COAST FEDERAL OR BY THE
FEDERAL GOVERNMENT. THE COMMON STOCK IS SUBJECT TO INVESTMENT RISK AND MAY LOSE
VALUE.
If anyone asserts that the shares of Common Stock are federally insured or
guaranteed, or are as safe as an insured deposit, I should call the Office of
Thrift Supervision's Southeast Regional Director, Mr. Jack Ryan, at (404)
888-0771.
I further certify that, before purchasing shares of Common Stock of the Company,
I received a copy of the Prospectus dated May XX, 2004 which discloses the
nature of the shares of Common Stock being offered thereby and describes the
following risks involved in an investment in the Common Stock under the heading
"Risk Factors" beginning on page xx of the Prospectus:
1. Our loan portfolio possesses increased risk due to our substantial number of multifamily, commercial
real estate, commercial business and consumer loans, which could increase the level of our
provision for loan losses. (page xx)
2. Our regulators required us to stop certain types of lending until we implemented new policies and
procedures and hired additional personnel. (page xx)
3. Our loan portfolio possesses increased risk due to its rapid expansion and the unseasoned nature of the
portfolio. (page xx)
4. Our non-performing loans and classified assets have increased substantially in the past year. If our
allowance for loan losses is not sufficient to cover our actual losses, our income may be
negatively affected. (page xx)
5. Our chief executive officer is a critical part of our successful operation. (page xx)
6. Changes in interest rates may hurt our profits. (page xx)
7. After this offering, our return on equity will be low compared to other companies and our compensation
expenses will increase. This could negatively impact the price of our stock. (page xx)
8. We intend to grant stock options and restricted stock to the board and management following the stock
offering which could reduce your ownership interest. (page xx)
9. Persons who purchase stock in the offering will own a minority of Atlantic Coast Federal Corporation's
common stock and will not be able to exercise voting control over most matters put to a vote of
stockholders. (page xx)
10. Our board, management and employees will potentially own over 25% of the stock sold in the offering. (page xx)
11. Holders of Atlantic Coast Federal Corporation common stock may not be able to sell their shares when
desired if a liquid trading market does not develop, or for $10.00 or more per share even if a
liquid trading market develops. (page xx)
12. Management will have substantial discretion over investment of the offering proceeds and may make
investments with which you disagree. (page xx)
13. Strong competition in our primary market area may reduce our ability to attract and retain deposits and
obtain loans. (page xx)
14. If economic conditions deteriorate, our results of operations and financial condition could be adversely
impacted as borrowers' ability to repay loans declines and the value of the collateral securing
our loans decreases. (page xx)
15. Office of Thrift Supervision policy on remutualization transactions could prohibit acquisition of
Atlantic Coast Federal Corporation, which may lower our stock price. (page xx)
16. We operate in a highly regulated environment and we may be adversely affected by changes in laws and
regulations. (page xx)
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Signature Date
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Signature Date
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