Pennsylvania Residents. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person criminal and civil penalties. Signed, sealed and delivered this day of , 20 Signature of Defendant
Pennsylvania Residents. By purchasing an Investment Certificate pursuant to the exemption provided in Section 203(d) of the Pennsylvania Securities Act of 1972, Pennsylvania residents agree not to sell the securities purchased under the exemption within 12 months after the date of purchase, except in accordance with 64 Pennsylvania Code § 204.011 If you have accepted an offer to purchase these Certificates and have received a written notice explaining your right to withdraw your acceptance pursuant to section 207(m)(2) of the Pennsylvania Securities Act of 1972, you may elect, within two business days from the date of receipt by the issuer of your binding contract of purchase or, in the case of a transaction in which there is no binding contract of purchase, within two business days after you make the initial payment for the Certificates being offered, to withdraw you acceptance and receive a full refund of all moneys paid by you. Your withdrawal of acceptance will be without any further liability to any person. To accomplish this withdrawal, you need only send a written notice (including a notice by facsimile or electronic mail) to United Pentecostal Church Development Fund, Inc. indicating your intention to withdraw. FOR OFFICE USE ONLY Security Number: Interest Rate: Representative: UNITED PENTECOSTAL CHURCH DEVELOPMENT FUND, Inc. d/b/a United Pentecostal Church Loan Fund INDIVIDUAL PURCHASE APPLICATION AND AGREEMENT If you have additional questions about this application, please call (000) 000-0000. Please print clearly using a ballpoint pen. The offer and sale of Investment Certificates (“Certificates”) are subject to the terms of the United Pentecostal Church Development Fund, Inc. d/b/a United Pentecostal Church Loan Fund Offering Circular dated April 1, 2020, as may be supplemented, amended and restated (“Offering Circular”), which is incorporated herein by reference. The United Pentecostal Church Development Fund, Inc. d/b/a United Pentecostal Church Loan Fund reserves the right to refuse your application and not offer or sell any Certificate to you for any reason. □ NEW APPLICATION □ CHANGE OF INFORMATION PART I: INVESTOR INFORMATION Primary Applicant Name Social Security or Tax I.D. Number Date of Birth: mo/day/year Email Address (optional) Address City State Zip ( ) ( ) ( ) Home Phone Work Phone Mobile Phone This application is to be used by individual applicants. You may select only one of the following additional ownership categories. If you do not select any of the...
Pennsylvania Residents. If you have accepted an offer to purchase these Certificates and have received a written notice explaining your right to withdraw your acceptance pursuant to section 207(m)(2) of the Pennsylvania Securities Act of 1972, you may elect, within two business days from the date of receipt by the issuer of your binding contract of purchase or, in the case of a transaction in which there is no binding contract of purchase, within two business days after you make the initial payment for the Certificates being offered, to withdraw you acceptance and receive a full refund of all moneys paid by you. Your withdrawal of acceptance will be without any further liability to any person. To accomplish this withdrawal, you need only send a written notice (including a notice by facsimile or electronic mail) to United Pentecostal Church Development Fund, Inc. indicating your intention to withdraw. Georgia Residents: See the Offering Circular for right of rescission.
Pennsylvania Residents. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties Oregon Residents : Any person who, knowingly and with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement that is relied upon by the insurer and is material to the content of the policy and to the risk assumed by the insurer, may be prosecuted for insurance fraud. There is no time limit on contestability in the event of fraud on the part of the insured.
Pennsylvania Residents. You have the right to withdraw from this purchase agreement and receive a full refund of all monies paid by you. The right must be exercised within two business days. The procedure to be followed in exercising the right is explained in the Offering Circular.
Pennsylvania Residents. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties Oregon Residents : Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
Pennsylvania Residents. Residents of the Commonwealth of Pennsylvania can only transfer the Securities offered hereby in accordance with the provisions of section 203(d) of the Pennsylvania Securities Act of 1972 and are subject to the following conditions:
Pennsylvania Residents. The undersigned hereby acknowledges that the Company is relying upon the exemption from registration of securities set forth in Section 203(d) of the Pennsylvania Securities Act of 1972, as amended (the "Pennsylvania Act") in connection with the sale of the Units to the undersigned. In accordance with the requirements of Section 203(d) of the Pennsylvania Act, the undersigned hereby agrees not to sell his Units within twelve (12) months from the date of purchase except pursuant to Section 204.01 of the Blue Sky Regulations of the Pennsylvania Securities Act of 1972. Additionally, the undersigned is aware of the right of withdrawal under Section 207(m) of the Act described in the introductory pages of the Memorandum.
Pennsylvania Residents. You have the right to withdraw from this purchase agreement and receive a full refund of all monies paid by you. The right must be exercised within two business days. The procedure to be followed in exercising the right is explained in the Offering Circular. AUTHORIZING RESOLUTION FORM Name of Organization RESOLVED, that this (check one) Corporation Limited Liability Company Partnership Unincorporated Association Other (specify) is authorized to invest in securities offered by Church Development Fund, Inc. (CDF), and be it further RESOLVED, that this authority will continue until revoked by further action of the governing body of this organization, and be it further RESOLVED, that the following individuals, whose signatures appear below Name and Title Name and Title Name and Title Name and Title Name and Title each has authority to direct investments in CDF securities and to execute documents on behalf of the organization, and be it further RESOLVED, that transactions in excess of $ of the organization’s investments will require authorized signatures, and be it further RESOLVED, that this organization agrees to the terms printed on each Certificate, Note or Agreement issued in connection with its investment(s), and to CDF’s Offering Circular, as to all investments with CDF and redemptions of such investments. The undersigned certify that they are duly authorized officers of the organization or have due authority on behalf of the above-named organization, and that the foregoing is a true copy of the resolutions duly adopted by the organization’s Board of Directors, or other governing body, and that the sig- natures appearing on this form are those of the persons authorized to bind the organization in accordance with said resolutions. SIGNED BY X Signature Print Name and Title Date CONFIRMED BY X Signature
Pennsylvania Residents. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. New York residents must sign acknowledging that you have read the New York Fraud Warning above. Signature of Defendant xxx.xxxxxxxxxx-xxx.xxx Accredited Surety and Casualty Company, Inc. A Xxxxxxx & Quilter Group Company X.X. Xxx 000000 • Xxxxxxx, XX 00000-0000 xxxx.xxxxxxx@xxxxxxxxxx-xxx.xxx 800-432-2799 UTAH BAIL BOND APPLICATION AND AGREEMENT (Please answer each question in full. Please print answers) You, the undersigned Defendant (“Defendant” or “you”), hereby represent and warrant that the following declarations made and answers given are true, complete and correct and are made for the purpose of inducing Accredited Surety and Casualty Company, Inc. (“Surety”) to issue, or cause to be issued, bail bond(s) or undertaking(s) for you (singularly or collectively the “Bond”), using power of attorney number(s)
