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 following options, we will issue the Certificate solely in the name of the primary applicant. □ Joint Tenants. If you select this option, we will issue the Certificate to the primary applicant and joint applicant as joint tenants with right of survivorship, unless you elect below to hold this Certificate as tenants-in-common. We will honor the request of either co-owner to redeem a Certificate, effect a transfer or take any other action requiring the consent of the holder of the Certificate. Joint Applicant (if applicable) 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 □ Tenants-in-Common. We elect to hold this Certificate as tenants-in-common, not as joint tenants with right of survivorship. For joint applications, please indicate the number of signatures required to process a redemption request: □ (1) □ (2) □ Trust. If you check this box, the Certificate will be issued in the name of the primary applicant, as trustee of the trust. If there is more than one trustee, each trustee must be identified in the purchase application Name and Date of Trust Name of Trustee Name of Additional Trustee (If Applicable)
Appears in 2 contracts
Samples: upciloanfund.org, upciloanfund.org
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 NumberGeorgia Residents: Interest RateSee the Offering Circular for right of rescission. SPOUSAL CONSENT For applicants that are married and reside in a community property state, please review the following: 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 applicationare married, please call reside in a community property or marital property state (000listed below) 000-0000and designate someone other than your spouse as your sole primary beneficiary, your spouse must sign below. Please print clearly using a ballpoint pen(AZ, CA, ID, LA, NV, NM, TX, WA and WI residents only) I am the spouse of the Certificate Owner named above. The offer and sale of Investment Certificates (“Certificates”) are subject I give to the terms owner any interest I have in the Certificate. Therefore, I agree to my spouse’s naming of the a primary beneficiary other than myself. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. I also acknowledge that I shall have no claim whatsoever against 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”for any payment made to my spouse’s named beneficiary(ies), which is incorporated herein by reference. The X Signature of Certificate Owner’s Spouse Date Spouse of United Pentecostal Church Development Fund, Inc. d/b/a United Pentecostal Church Loan Fund reserves (the right “Fund”) is required to refuse obtain your correct Taxpayer Identification Number (for individuals this is your social security number) in order to report to the Internal Revenue Service (IRS) interest paid to you. The Fund, like any other payer of interest or dividends, must withhold 28% of the interest paid if you fail to furnish the Fund with your correct Taxpayer Identification Number or if you fail to sign the acknowledgement portion of the Purchase Application. This is referred to as “backup withholding”. For more information on backup withholding, please visit xxx.XXX.xxx. Under penalties of perjury, I certify that 1) the Social Security Number or the Tax Identification Number shown on this application is correct; 2) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and not offer or sell any Certificate 3) I am a U.S. person (including a U.S. resident alien). (NOTE: You must cross out item 2) above if you have been notified by the IRS that you are currently subject to backup withholding because you for any reason. □ NEW APPLICATION □ CHANGE OF INFORMATION PART I: INVESTOR INFORMATION Primary Applicant failed to report all interest and dividends on your tax return.) X Name Signature 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 following options, we will issue the Certificate solely in the name of the primary applicant. □ Joint Tenants. If you select this option, we will issue the Certificate to the primary applicant and joint applicant as joint tenants with right of survivorship, unless you elect below to hold this Certificate as tenants-in-common. We will honor the request of either co-owner to redeem a Certificate, effect a transfer or take any other action requiring the consent of the holder of the Certificate. Joint Applicant (if applicable) 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 □ Tenants-in-Common. We elect to hold this Certificate as tenants-in-common, not as joint tenants with right of survivorship. For joint applications, please indicate the number of signatures required to process a redemption request: □ (1) □ (2) □ Trust. If you check this box, the Certificate will be issued in the name of the primary applicant, as trustee of the trust. If there is more than one trustee, each trustee must be identified in the purchase application Name and Date of Trust Name of Trustee Name of Additional Trustee (If Applicable)Address
Appears in 2 contracts
Samples: upciloanfund.org, upciloanfund.org
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. INC. d/b/a United Pentecostal Church Loan Fund INDIVIDUAL ORGANIZATION 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 Private Offering Circular Memorandum dated April 1, 20202021, as may be supplemented, amended and restated (“Offering CircularMemorandum”), 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 following options, we will issue the Certificate solely in the name of the primary applicant. □ Joint Tenants. If you select this option, we will issue the Certificate to the primary applicant and joint applicant as joint tenants with right of survivorship, unless you elect below to hold this Certificate as tenants-in-common. We will honor the request of either co-owner to redeem a Certificate, effect a transfer or take any other action requiring the consent of the holder of the Certificate. Joint Applicant (if applicable) 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 □ Tenants-in-Common. We elect to hold this Certificate as tenants-in-common, not as joint tenants with right of survivorship. For joint applications, please indicate the number of signatures required to process a redemption request: □ (1) □ (2) □ Trust. If you check this box, the Certificate will be issued in the name of the primary applicant, as trustee of the trust. If there is more than one trustee, each trustee must be identified in the purchase application Name and Date of Trust Name of Trustee Name of Additional Trustee (If Applicable)INFORMATION
Appears in 1 contract
Samples: upciloanfund.org
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, 20202021, 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 ( ) ( ) 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 following options, we will issue the Certificate solely in the name of the primary applicant. □ Joint Tenants. If you select this option, we will issue the Certificate to the primary applicant and joint applicant as joint tenants with right of survivorship, unless you elect below to hold this Certificate as tenants-in-common. We will honor the request of either co-owner to redeem a Certificate, effect a transfer or take any other action requiring the consent of the holder of the Certificate. Joint Applicant (if applicable) Name Social Security or Tax I.D. Number Date of Birth: mo/day/year Email Address (optional) Address City State Zip ( ) ( ) City State ( ) Zip Home Phone Work Phone Mobile Phone □ Tenants-in-Common. We elect to hold this Certificate as tenants-in-common, not as joint tenants with right of survivorship. For joint applications, please indicate the number of signatures required to process a redemption request: □ (1) □ (2) □ Trust. If you check this box, the Certificate will be issued in the name of the primary applicant, as trustee of the trust. If there is more than one trustee, each trustee must be identified in the purchase application Name and Date of Trust Name of Trustee Name of Additional Trustee (If Applicable)
Appears in 1 contract
Samples: upciloanfund.org
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 NumberGeorgia Residents: Interest RateSee the Offering Circular for right of rescission. SPOUSAL CONSENT For applicants that are married and reside in a community property state, please review the following: 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 applicationare married, please call reside in a community property or marital property state (000listed below) 000-0000and designate someone other than your spouse as your sole primary beneficiary, your spouse must sign below. Please print clearly using a ballpoint pen(AZ, CA, ID, LA, NV, NM, TX, WA and WI residents only) I am the spouse of the Certificate Owner named above. The offer and sale of Investment Certificates (“Certificates”) are subject I give to the terms owner any interest I have in the Certificate. Therefore, I agree to my spouse’s naming of the a primary beneficiary other than myself. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. I also acknowledge that I shall have no claim whatsoever against 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”for any payment made to my spouse’s named beneficiary(ies), which is incorporated herein by reference. The X Signature of Certificate Owner’s Spouse Date Spouse of SUBSTITUTE W-9 FORM United Pentecostal Church Development Fund, Inc. d/b/a United Pentecostal Church Loan Fund reserves (the right “Fund”) is required to refuse obtain your correct Taxpayer Identification Number (for individuals this is your social security number) in order to report to the Internal Revenue Service (IRS) interest paid to you. The Fund, like any other payer of interest or dividends, must withhold 28% of the interest paid if you fail to furnish the Fund with your correct Taxpayer Identification Number or if you fail to sign the acknowledgement portion of the Purchase Application. This is referred to as “backup withholding”. For more information on backup withholding, please visit xxx.XXX.xxx. Under penalties of perjury, I certify that 1) the Social Security Number or the Tax Identification Number shown on this application is correct; 2) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and not offer or sell any Certificate 3) I am a U.S. person (including a U.S. resident alien). (NOTE: You must cross out item 2) above if you have been notified by the IRS that you are currently subject to backup withholding because you for any reason. □ NEW APPLICATION □ CHANGE OF INFORMATION PART I: INVESTOR INFORMATION Primary Applicant failed to report all interest and dividends on your tax return.) X Name Signature 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 following options, we will issue the Certificate solely in the name of the primary applicant. □ Joint Tenants. If you select this option, we will issue the Certificate to the primary applicant and joint applicant as joint tenants with right of survivorship, unless you elect below to hold this Certificate as tenants-in-common. We will honor the request of either co-owner to redeem a Certificate, effect a transfer or take any other action requiring the consent of the holder of the Certificate. Joint Applicant (if applicable) 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 □ Tenants-in-Common. We elect to hold this Certificate as tenants-in-common, not as joint tenants with right of survivorship. For joint applications, please indicate the number of signatures required to process a redemption request: □ (1) □ (2) □ Trust. If you check this box, the Certificate will be issued in the name of the primary applicant, as trustee of the trust. If there is more than one trustee, each trustee must be identified in the purchase application Name and Date of Trust Name of Trustee Name of Additional Trustee (If Applicable)Address
Appears in 1 contract
Samples: upciloanfund.org
