Exhibit 4.4
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Consumer Portfolio Services, Inc. Subscription Agreement
Renewable Unsecured Subordinated Note Subscription Agreement
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To purchase a renewable unsecured subordinated note(s), please complete this
form and write a check made payable to Consumer Portfolio Services, Inc. Send
this form along with your check and any other documents requested below to the
selling agent for the notes, XXXXXX XXXXXXXXXX LTD., 00000 XXXXXXX XXXXXXXXX,
XXXXX 000, XXXXXXXXXXX, XXXXXXXXX 00000. If you have any questions, call the
selling agent for the notes, XXXXXX XXXXXXXXXX LTD., at 000-000-0000.
NOTE PURCHASE AMOUNT (minimum principal amount $1,000 per note)
INTEREST PAYMENT SCHEDULE (please select one for each note)
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NOTE TERM PRINCIPAL AMOUNT MONTHLY* QUARTERLY SEMI-ANNUALLY ANNUALLY MATURITY
Three Month $__________ [ ] [ ] N/A N/A [ ]
Six Month $__________ [ ] [ ] [ ] N/A [ ]
One Year $__________ [ ] [ ] [ ] [ ] [ ]
Two Year $__________ [ ] [ ] [ ] [ ] [ ]
Three Year $__________ [ ] [ ] [ ] [ ] [ ]
Four Year $__________ [ ] [ ] [ ] [ ] [ ]
Five Year $__________ [ ] [ ] [ ] [ ] [ ]
Ten Year $__________ [ ] [ ] [ ] [ ] [ ]
TOTAL $__________ *Monthly interest payment date (e.g. 1st, 15th, etc.)
Form of Ownership (please select one)
[ ] Individual Investor (with optional beneficiary) [ ] Custodian for a Minor
[ ] Joint Tenants with Right of Survivorship [ ] Other XXX, SEP, 401(k), 403(b), Xxxxx, trust,
corporation, partnership, etc.
(Please include with this form a trust
resolution or the appropriate corporation
or partnership documents authorizing you
to make this investment.)
Note Purchaser (please circle one)
Full Name of Individual Investor/First Joint Tenant/Minor/Entity/Administrator/Trustee
__________________________________________________________ _____________________________________ _____________________________
First Name Middle Name Last Name Social Security Number/Tax ID Number Date of Birth (if applicable)
Full Name of Beneficiary/Second Joint Tenant/Custodian/Transfer on Death (please circle one if applicable)
__________________________________________________________ _____________________________________ _____________________________
First Name Middle Name Last Name Social Security Number/Tax ID Number Date of Birth (not required
for custodians)
Other Family CPS Note Investors_____________________________________________________________________________________________________
Primary Address (Original correspondence will be sent Secondary Address (Optional--copies of correspondence will be sent
to this address.) to this address.)
_____________________________________________________ __________________________________________________________________
Individual Investor, XXX Administrator, Trustee, Beneficiary, XXX Owner, Joint Tenant, Partner, etc.
Custodian, Partnership, etc.
_____________________________________________________ __________________________________________________________________
Address Address
_____________________________________________________ __________________________________________________________________
City State Zip City State Zip
_____________________________________________________ __________________________________________________________________
Daytime Phone (Include Area Code) E-mail Address Daytime Phone (Include Aera Code) E-mail Address
DIRECT DEPOSIT CPS will electronically deposit your principal and interest
payments directly into the account listed in the Direct Deposit section on the
reverse side of this form. Please complete and sign the reverse side of this
form for automatic deposit to either your checking or savings account.
PASSWORD When you call Xxxxxx Xxxxxxxxxx Ltd. to discuss your investment, you
may be asked to verify your identification by answering the following question.
What is your mother's maiden name?______________________________________________
CERTIFICATION Under penalties of perjury, I hereby declare and certify that: (i)
I am a bona fide resident of the state listed in the primary mailing address;
(ii) I have received and read the prospectus provided by Consumer Portfolio
Services, Inc. and understand the risks related to the notes and to Consumer
Portfolio Services, Inc.; (iii) Xxxxxx Xxxxxxxxxx Ltd. has neither recommended
this investment to me nor given me investment, legal or tax advice regarding the
notes and the creditworthiness of Consumer Portfolio Services, Inc.; (iv) I have
independently determined that this investment is suitable for me without relying
on such advice from Xxxxxx Xxxxxxxxxx Ltd.; (v) the notes are illiquid due to
significant transfer restrictions and the lack of a secondary market; (vi) I
risk the loss of my entire principal amount and all accrued but unpaid interest
when purchasing the notes and have the financial ability to withstand these
losses; (vii) I am purchasing the notes to fulfill my investment objective of
earning current taxable interest income; (viii) the social security number or
tax identification number listed above is correct; and (ix) I am not subject to
backup withholding, either because the Internal Revenue Service has not notified
me that I am subject to backup withholding as a result of a failure to report
all interest or dividends or I have been notified that I am no longer subject to
backup withholding. I understand that my purchase offer is subject to the terms
contained in the prospectus, may be rejected in whole or in part and will not
become effective until accepted by Consumer Portfolio Services, Inc. or its
selling agent.
_________________________________________________________________________________________________
Signature of Individual Investor/First Joint Tenant/Custodian/Authorized Person Date
_________________________________________________________________________________________________
Signature of Second Joint Tenant (If applicable) Date
Office Use Only ACTP________ DATE_________ COMM_________ ADVR_________ SHDB_________ SALU_________
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DIRECT DEPOSIT
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Direct Deposit Account Information (please check one)
[ ] I currently receive direct deposit payments from an existing CPS note. Please
deposit all principal and interest payments for this new note into the same
account.
[ ] Please deposit my payments into the account listed below. (If this option is
chosen, the account owner must attach a VOIDED check -- or deposit slip if this
is a savings account -- to the bottom of this form.)
_______________________________________________________________________________________________________________
Account Owner Name(s)
__________________________________________ [ ] Checking [ ] Savings [ ] Other
Account Number
[ ][ ][ ][ ][ ][ ][ ][ ][ ] __________________________________ ____________________________
Bank Routing Number (9 digits) Bank Name Branch Location
Some financial institutions (e.g. brokerage firms, custodians, mutual savings
banks, credit unions, money market funds, etc.) also require "for further
credit" information to correctly indentify direct deposit accounts. If your
financial institution requires this additional information, please list it
below. If you are unsure if this additional information is required, please call
your financial institution.
For further credit:____________________________________________________________________________________________
DIRECT DEPOSIT AUTHORIZATION
As the investor of record and authorized signatory of the account listed above,
I hereby authorize Consumer Portfolio Services, Inc., its affiliates, or its
agents (collectively referred to hereinafter as "CPS") to deposit interest and
principal payments owed to me, by initiating credit entries in the account to my
financial institution listed on this form. Further, I authorize my financial
institution to accept and to credit any credit entries initiated by CPS to the
listed account. In the event of an erroneous credit entry, I also authorize CPS
to debit the account for an amount not to exceed the original amount of the
erroneous credit.
This authorization is to remain in full force and effect until CPS and my
financial institution have received written notice from me of its termination in
such time and in such manner as to afford CPS and my financial institution
reasonable opportunity to act on it. In the event the listed account is closed I
will promptly notify CPS of an alternate account into which payments can be
made.
______________________________________________________ ______________________________________________________
Authorized Signature Date
Mail to:
Xxxxxx Xxxxxxxxxx Ltd.
00000 Xxxxxxx Xxxxxxxxx
Xxxxx 000
Xxxxxxxxxxx, Xxxxxxxxx 00000
ATTACH VOIDED CHECK or DEPOSIT SLIP HERE
