EXHIBIT 99.1 FORM OF SUBSCRIPTION AGREEMENT FOR RIGHTS OFFERING
RIGHTS SUBSCRIPTION AGREEMENT
OHIO STATE BANCSHARES, INC.
RIGHTS OFFERING SUBSCRIPTION AGREEMENT
EXPIRATION DATE: _______________, 2002
We are conducting a RIGHTS OFFERING that entitles holders of our common
stock, as of the close of business on ________________, 2002 (the "Record
Date"), TO PURCHASE .3014 SHARE OF COMMON STOCK FOR EVERY ONE SHARE OF COMMON
STOCK THEN HELD (ROUNDED DOWN TO THE NEAREST WHOLE SHARE). Set forth below are
the number of shares of common stock that you are entitled to purchase in the
rights offering at a subscription price of $66 per share. No cash will be paid
by us for any subscription rights or fractional shares.
To subscribe for shares in the rights offering, we must receive a
properly completed and executed copy of this Rights Subscription Agreement by
_____________, 2002, together with a cashier's check, certified check, money
order, or personal check payable to "OHIO STATE BANCSHARES, INC." for an amount
equal to the number of shares subscribed for multiplied by $66.
FOR A MORE COMPLETE DESCRIPTION OF THE TERMS AND CONDITIONS OF THIS
OFFERING, PLEASE REFER TO THE PROSPECTUS DATED ____________, 2002, WHICH IS
INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON
REQUEST FROM OHIO STATE BANCSHARES, INC. BY CALLING XXXXXXX X. XXXXXXXX AT (740)
387-2265.
EXERCISE AND SUBSCRIPTION: The undersigned hereby irrevocably
subscribes for the number of shares of common stock indicated below, on the
terms and subject to the conditions specified in the prospectus, receipt of
which is hereby acknowledged.
Number of Shares You May Purchase under the Rights Subscription Privilege:
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RIGHTS OFFERING
1. Number of Rights Offering shares you are subscribing for:
_____________. (You may subscribe for any or all of the number of
shares listed above.)
2. Total Subscription Price: ______________ (Number of shares listed
on line 1 x $66 per share)
THE RIGHT TO SUBSCRIBE IN THE RIGHTS OFFERING IS NON-TRANSFERABLE
AND CAN ONLY BE EXERCISED IN THE EXACT TITLING AS APPEARS IN THE BOX ABOVE.
METHOD OF PAYMENT
Payment must be in the form of cashier's check, certified check, money
order, or personal check payable to "OHIO STATE BANCSHARES, INC."
If the aggregate amount enclosed is insufficient to purchase the total
number of shares on line 1, or if payment is enclosed but the number of shares
being subscribed for is not specified, the holder of this Subscription Agreement
shall be deemed to have subscribed for the maximum amount of shares in the
Rights Offering that could be subscribed for upon payment of such amount.
Any funds paid in excess of the total subscription price for the shares
you have the right to purchase in the Rights Offering will be returned to you by
mail as soon as practicable.
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Signature Date
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Signature of Joint Owner, if applicable Area Code and Telephone Number
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Street Address Social Security or Federal Taxpayer
Identification No.
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(City) (State) (Zip)
To be completed by Ohio State Bancshares, Inc.
Accepted as of ______________________, 2002, as to ___________ Shares.
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Xxxx X. Xxxxxxxxx
President and Chief Executive Officer
[SEE REVERSE SIDE FOR SUBSTITUTE FORM W-9]
SUBSTITUTE PART I - Taxpayer Identification
Form W-9 Number. For all accounts enter taxpayer number in
the appropriate box. For most individuals this is
your Social Security number. If you do not have a number or
if the account is in more than one name, contact office identified in
Instruction 6.
Department of the Treasury
the Internal Revenue Service .
Payer's Request for
Taxpayer
Identification Number
("TIN")
PART II - For Payees Exempt from Backup
Withholding Certification - Under penalties of
perjury, I certify that:
(1) The number shown on this form is my correct Taxpayer
Identification Number (or I am waiting for a number to
be issued to me), and
(2) I am not subject to backup withholding either because
(a) I am exempt from backup withholding; or (b) I have not
been notified by the Internal Revenue Service ("IRS") that I
am subject to backup withholding as a result of failure to
report all interest or dividends; or (c) the IRS has
notified me that I am no longer subject to backup
withholding.
CERTIFICATION GUIDELINES - You must cross
out item (2) above if you have been notified by the
IRS that you are subject to backup withholding because
of under-reporting interest or dividends on your tax
return. However, if after being notified by the IRS
that you were subject to backup withholding you
received another notification from the IRS that you
are no longer subject to backup withholding, do not
cross out item (2).
Signature (X)___________________________ Date ________________, 2002
SUBSTITUTE FORM W-9. Each subscriber must provide a correct
taxpayer identification number ("TIN") and sign and date the Substitute
W-9 on the Transmittal. In general, if a subscriber is an individual,
the TIN is the social security number of such individual. See the
enclosed guidelines. If the correct TIN is not provided, the subscriber
may be subject to a $50 penalty imposed by the Internal Revenue Code.
For further information regarding instructions for completing the
Substitute Form W-9 (including how to obtain a TIN if you do not have
one and how to complete the Substitute Form W-9 if shares are held in
more than one name), contact Xxxxxxx X. Xxxxxxxx, Ohio State
Bancshares, Inc., 000 Xxxxx Xxxx Xxxxxx, Xxxxxx, Xxxx 00000, (740)
387-2265.
