EXHIBIT 99
Subscription Agreement
MOUND CITY FINANCIAL SERVICES, INC.
PROSPECTUS DATED _________________, 1998
IMPORTANT: PLEASE READ CAREFULLY BEFORE SIGNING:
SIGNIFICANT REPRESENTATIONS ARE CALLED FOR
SUBSCRIPTION AGREEMENT
Mound City Financial Services, Inc.
c/o Xxxxxx X. Xxxx, Xx.
00 Xxxx Xxxx Xxxxxx
Xxxxxxxxxxx, Xxxxxxxxx 00000
By executing this Subscription Agreement, the undersigned,
________________________ __________, offers to subscribe for and purchase
__________ shares of Common Stock of Mound City Financial Services, Inc., a
Wisconsin corporation ("Company"), at a price of $310.00 per share, pursuant to
the terms and conditions of the Offering described in the Prospectus of the
Company dated ____________, 1998 (the "Prospectus"), and the terms of this
Subscription Agreement. (Unless otherwise defined herein, capitalized terms in
this Subscription Agreement have the same meaning as in the Prospectus.) The
undersigned agrees to deliver, with the executed Subscription Agreement, payment
in full of the subscription price for all shares of Common Stock subscribed for
under this Agreement. The Offering expires on _______________, 1998, unless
extended. The undersigned presently owns ____________ shares of common stock.
1. Representations. As an inducement to the Company to accept this
subscription, the undersigned represents, warrants, and agrees as follows:
(a) The undersigned has received, carefully reviewed, and is familiar
with the Prospectus and has had an opportunity to ask questions
of and receive additional information from Company
representatives.
(b) The information supplied in this Subscription Agreement is true,
accurate, and complete. The undersigned acknowledges that the
Company is relying upon the accuracy and completeness of the
representations and warranties contained in this Agreement in
complying with its obligations under applicable securities laws.
(c) If the undersigned is other than an individual, this Subscription
Agreement has been duly authorized by all necessary action on the
part of the undersigned, has been duly executed by an authorized
officer or representative of the undersigned, and is a legal,
valid and binding obligation of the undersigned enforceable in
accordance with its terms.
2. Restriction Transfer. The undersigned agrees that he or she will not
transfer, sell or assign the Common Stock purchased pursuant to this
Subscription Agreement unless the Common Stock has been registered pursuant to
the Securities Act of 1933 or is exempt from the registration requirement, and
is not in violation of applicable state securities laws.
3. Additional Shares. _____ If checked here, the undersigned would like the
opportunity to purchase additional shares of Common Stock at $310.00 per share
if other shareholders do not subscribe for all the Common Stock to which they
are entitled. The number of additional shares of Common Stock that the
undersigned would like to purchase is ______.
4. Name in Which Title is to be Held.
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5. Xxxxxx in Which Title is to be Held. (check one)
_____ Individual Ownership
_____ Survivorship Marital Property (to surviving
spouse on death of one spouse)
_____ Joint Tenant with Right of Survivorship (for
persons other than husband and wife)
_____ Partnership*
_____ Tenants in Common
_____ Corporation*
_____ Limited Liability Company ("LLC")*
_____ Trust*
_____ Other (specify:______________________)*
*If Shares are being subscribed for by a corporation, partnership, LLC or other
organization, the attached Certificate of Authorized Signer must also be
completed.
SUBSCRIBER SIGNATURE(S)
Dated: _________________
Number of Shares subscribed for on page 1: _____
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Signature Signature
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Name to Appear on Stock Certificate Name Typed or Printed
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Residence Address Residence Address
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City, State and Zip Code City, State and Zip Code
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Tax Identification or Tax Identification or
Social Security Number Social Security Number
(PLEASE MAKE CHECKS PAYABLE TO MOUND CITY FINANCIAL SERVICES, INC.)
THIS SUBSCRIPTION AGREEMENT MUST BE POSTMARKED ON OR BEFORE THE EXPIRATION DATE
OF THE OFFERING AND MAILED TO MOUND CITY FINANCIAL SERVICES, INC., C/O XXXXXX X.
XXXX, XX., 00 XXXX XXXX XXXXXX, XXXXXXXXXXX, XXXXXXXXX 00000, OR DELIVERED ON OR
BEFORE 5:00 P.M. LOCAL TIME ON THE EXPIRATION DATE TO MOUND CITY FINANCIAL
SERVICES, INC., C/O XXXXXX X. XXXX, XX., 00 XXXX XXXX XXXXXX, XXXXXXXXXXX,
XXXXXXXXX 53818. THE EXPIRATION DATE IS _________________, 1998, UNLESS
EXTENDED.
CERTIFICATE OF AUTHORIZED SIGNER
(To be completed if shares of Common Stock are being
subscribed for by a corporation, partnership, or
other organization.)
I, ______________________________, am the duly appointed and acting
______________ of _________________________, of ___________________, Wisconsin
(the "Organization").
I certify that I am empowered and duly authorized by the Organization to
execute and carry out the terms of the Subscription Agreement and to purchase
and hold the shares of Common Stock, and certify further that the Subscription
Agreement has been duly and validly executed on behalf of the Organization and
constitutes a legal and binding obligation of the Organization.
IN WITNESS WHEREOF, I have set my hand this _____ day of
__________________.
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(Signature)
ACCEPTANCE
This Subscription Agreement for _____ shares is accepted as of
________________.
MOUND CITY FINANCIAL SERVICES, INC.
By_________________________________
Its________________________________
