EXHIBIT 99.1
FORM OF SUBSCRIPTION AGREEMENT
BALANCED LIVING, INC.
SUBSCRIPTION AGREEMENT
FOR PURCHASERS OF COMMON STOCK UNITS
. CASHIER'S CHECKS MUST BE MADE PAYABLE TO: BALANCED LIVING, INC.
. FOR XXX OR PENSION INVESTORS: INCLUDE BANK CUSTODIAL
DOCUMENTS
. CHECKS AND DOCUMENTS MUST BE DELIVERED TO: BALANCED LIVING, INC.
0000 XXXXX XXXXXXXX XX.
XXXXX X
XXXX XXXX XXXX, XX 00000
1. UNITS PURCHASED:
This subscription is for _____________ UNITS in the total purchase
amount of $ _____________, to be registered as follows:
2. FORM OF OWNERSHIP: Xxxx only one box:
SINGLE PERSON -- one signature required
JOINT TENANTS WITH RIGHT OF SURVIVORSHIP -- all parties must sign
HUSBAND AND WIFE, AS COMMUNITY PROPERTY -- two signatures required
TENANTS IN COMMON all parties must sign
CORPORATION
CUSTODIAN UGTM -- custodian signature required
MARRIED PERSON/SEPARATE PROPERTY -- one signature required
TRUST -- trustee signature(s) required. ALL SECTIONS MUST BE FILLED
IN Print Trustee name(s) (sign in Signature Section)
Trust Date | | | | | | | | |
Month Day Year
For the benefit of:
TENANTS BY THE ENTIRETIES -- two signatures required
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PARTNERSHIP
CUSTODIAN (for Taxable Person)--custodian signature required
3. INVESTOR INFORMATION: Please print name(s) in which Notes are to be
registered. All interest and principal payments and correspondence will go
to this address unless another address is listed in Section 4.
Name (1st) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Name (2nd) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Address | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
City | | | | | | | | | | | | | | | | | | State | | | Zip Code | | | |
Daytime Phone Number | | | |-| | | |-| | | | |
State of Residence | | | How Long? Since | | | | |
Enter the Taxpayer identification number in the appropriate box. Note: If
the account is in more than one name, the number should be that of the first
person listed.
Social Security No. | | | |-| | |-| | | | | and/or
Taxpayer Identification No. | | |-| | | | | |
| | |-| | |-| | | $| | | | | | | | $| | | | | | | | | | |M | |F
Date of Birth Gross Income for Estimated Net Worth Sex
Past 12 Months as of This Date
If Subscription is a trust, date of trust formation | | |-| |-| | |
4. OTHER MAILING ADDRESS: If you want shareholder mailings sent to an
address other than in Section 3, please fill in below (required for XXX or
Pension accounts).
Account Number | | |-| | | | | | |
Name of Custodian | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Address | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
City | | | | | | | | | | | | | | | | | | | State | | | Zip Code | | | | |
The undersigned Investor, hereby certifies that a current copy of the
Balanced Living Inc. Prospectus dated December , 1998 has been delivered
to, and received by the Investor prior to making any investment decision,
and the Investor has had a full opportunity to ask questions of, and
receive information responsive to his questions from, Balanced Living, Inc.
prior to investing in the Units.
NOT TO BE EXECUTED UNTIL RECEIPT OF PROSPECTUS
5. SIGNATURES:
X / /
Authorized Signature of Investor Date
X / /
Signature of Joint Investor (if any) Date
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