Exhibit 4.2
Certificate of Indebtedness
No. ________________ $________________
CORNERSTONE MINISTRIES INVESTMENTS, INC. ("Issuer" or "we" and related pronouns)
promises to pay to ______________________________________________________ or
registered assigns ("you" or "holder"), the principal sum of
________________________________________ Dollars ($__________).
Taxpayer I.D. Number: __________________ CUSIP Number:_________________.
This Certificate of Indebtedness may evidence (1) a 9% five-year certificate or
(2) a graduated certificate, in each case, as described in the prospectus and
the Purchase Agreement under which such certificate is sold. This Certificate of
Indebtedness evidences a: __________________.
Generally, certificates of Indebtedness will be registered in book entry form
only and the investor will receive only a written confirmation of their
investment, and not an actual certificate. We issue Certificates of Indebtedness
under a Trust Indenture; the trustee under the Trust Indenture is Trinity Trust
Company.
Dated:_________________, 2003
Trinity Trust Company, as Trustee, CORNERSTONE MINISTRIES
certifies that this is one of the INVESTMENTS, INC.
Certificates referred to in the Trust
Indenture.
By:______________________________ By:______________________________
Name: Name:
Title: Title:
[SEAL] [SEAL]
[Back of Certificate]
The registered owner of this Certificate shall be entitled to all the rights and
privileges and subject to the conditions, limitations and agreements set forth
in the Trust Indenture executed in connection with the offering of the
securities described on the front side of this Certificate, the terms,
covenants, conditions and agreements of such Trust Indenture being incorporated
herein by this reference.
The Issuer will furnish to any Certificate owner upon written request and
without charge a copy of the Trust Indenture. Requests may be made to Xxxx X.
Xxxxxxxx, Cornerstone Ministries Investments, Inc., 0000 Xxxxxxx Xxxxxxx, Xxxxx
000, Xxxxxxx, Xxxxxxx 00000.
This Certificate is non-negotiable.
Abbreviations. Customary abbreviations may be used in the name of a Certificate
owner or an assignee, such as TEN COM (=tenants in common), TEN ENT (=tenants by
the entireties), JT TEN (= joint tenants with rights of survivorship and not as
tenants in common), CUST (= Custodian), and U/G/M/A (- Uniform Gifts to Minors
Act).
SECURITY POWER FORM:
THE FOLLOWING MUST BE COMPLETED TO TRANSFER YOUR CERTIFICATE TO ANOTHER
For value received I/We hereby sell, assign and transfer unto
(Name and address of Transferee must be printed or typed)
----------------------------------------------- ------/-----/-------
City State Zip Code Social Security Number
all right, title and interest to this Certificate, including all outstanding
principal and accrued interest, and do hereby irrevocably constitute and appoint
the Registrar to transfer the said Certificate on the books of the within named
Issuer, with full power of substitution in the premises and to issue a new
Certificate to the Transferee (New Owner). The Social Security Number of the
Transferee (New Owner) his/her name and mailing address where he/she wishes to
receive interest checks or notices must be provided to the Registrar along with
the transfer fee BEFORE TRANSFER can be completed. The transfer request must be
received 15 calendar days prior to an interest payment date.
If Joint Ownership, Both Must Sign Certificate
Date:____________, ___ __________________________________________
Signed (Registered Owner as Shown on Front)
In the presence of:
Authorized Signature Guarantee Signed (Registered Owner as Shown on Front)
Above Signatures must be guaranteed (not notarized) by a participant in a
Medallion Guarantee Program.
New Owner - Please check this form for accuracy before you sign. Your
Certificate will be registered exactly as shown. You will be charged a fee per
Certificate if you require further changes. You must sign below to verify your
Social Security Number. Please provide your daytime telephone number (___)
_____-______________.
Please send me/us a confirmation and retain Certificate.
Under penalties of perjury, I certify (1) that the number shown on this form is
my correct taxpayer identification number, and (2) that I am not subject to
backup withholding because: (a) I have not been notified that I am subject to
backup withholding as a result of failure to report all interest or dividends,
or (b) the Internal Revenue Service has notified me that I am no longer subject
to backup withholding.
______________________________________________________
Signature of Transferee whose number is shown at right
SS#_________-_______-________ Date:________________________
(or)
_______________________________________________
Signature of Authorized Signer for Transferee
TIN#_________-_______-________ Date:________________________
