EX-99.5 27 dex995.htm EXHIBIT 99.5 Exhibit 99.5

Exhibit 99.5

 

BANK LOGO HERE  

SEND OVERNIGHT PACKAGES TO:

Attn: Stock Information Center

10 S Wacker

Suite 3400

Chicago, IL 60606

 

(1) Number of Shares

   Price Per Share    (2) Total Amount Due            ORDER DEADLINE: The Subscription Offering ends at 12 noon, Central Time, on ___________, 2009. Your original Stock Order and Certification Form, properly executed and with the correct payment, must be received (not postmarked) at the address on the top of this form by the deadline or it will be considered void. Faxes or copies of this form will not be accepted. Harvard Illinois Bancorp, Inc. reserves the right to accept or reject improper order forms.
         x $10.00 =    $         .00           
    Minimum Number of Shares: 25 ($250). Maximum Number of Shares: 10,000 ($100,000). See instructions on Reverse Side      
                
(3a) Method of Payment- Check or Money Order
Enclosed is a personal check, bank check or money order made payable to Harvard Illinois Bancorp, Inc.
   $            .00      

 

(3b) Method of Payment- Deposit Account Withdrawal   (4) Purchaser Information (check one)

Harvard Savings Bank Deposit Account Number(s)

     Withdrawal Amount(s)   a.  ¨   Eligible Account Holder - Check here if you were a depositor with at least $50 on deposit with Harvard Savings Bank as of June 30, 2008. Enter information in Section 9 for all deposit accounts that you had at Harvard Savings Bank on June 30, 2008.
MARK THE    Savings  ¨       
ACCOUNT TYPE    CD         ¨    $ .00   b.  ¨   Supplemental Eligible Account Holder - Check here if you were a depositor with at least $50 on deposit with Harvard Savings Bank as of [supp date] but not an Eligible Account Holder. Enter information in Section 9 for all deposit accounts that you had at Harvard Savings Bank as of [supp date].
MARK THE    Savings  ¨       
ACCOUNT TYPE    CD         ¨    $ .00   c.  ¨   Other Members - Check here if you were a depositor of Harvard Savings Bank as of __________, 2009, or a borrower as of _____________ whose borrowings remain outstanding as of _____________, who were not able to subscribe for shares under the Eligible or Supplemental Account Holders Categories.
MARK THE    Savings  ¨       
ACCOUNT TYPE    CD         ¨    $ .00   d.  ¨   Local Community – People or trusts for the benefit of people who reside in the Illinois counties of McHenry or Grundy will receive preference in a community offering
         
        e.  ¨   General Public
   Total Withdrawal    $ .00    

(5) Check if you (or a household family member) are a: ¨  Director or Officer of Harvard Savings Bank or Harvard Illinois Bancorp, Inc.      ¨  Employee of Harvard Saving Bank or Harvard Illinois Bancorp, Inc.

(6) Maximum Purchaser Identification: ¨  Check here if you, individually or together with others (see section 7), are subscribing for the maximum purchase allowed and are interested in purchasing more shares if the two maximum purchase limitations are increased. See Section 1 of the Stock Order Form Instructions on the reverse side.

(7) Associates/Acting in Concert: ¨  Check here if you, or any associates or persons acting in concert with you, have submitted other orders for shares. If you check this box, list below all other orders submitted by you or your associates or by persons acting in concert with you.

 

Name(s) listed in Section 8 on other Order Forms

   Number of
Shares Ordered
  

Name(s) listed in Section 8 on other Order Forms

   Number of
Shares Ordered
        
        
        

(8) Stock Registration - Please Print Legibly and Fill Out Completely: (Note: The stock certificate and all correspondence related to this stock order will be mailed to the address provided below.)

 

¨ Individual    ¨ Individual Retirement Account    ¨ Corporation
¨ Joint Tenants    ¨ Uniform Transfer to Minors Act    ¨ Partnership
¨ Tenants in Common    ¨ Uniform Gift to Minors Act    ¨ Trust - Under Agreement Dated ______

 

Name

 

                  SS# or Tax ID

Name

 

                  SS# or Tax ID

Address

 

                  Daytime Telephone #

City

 

   State        Zip Code        County        Evening Telephone #

(9) Qualifying Accounts: You should list any accounts that you may have or had with Harvard Savings Bank in the box below. SEE THE STOCK ORDER FORM INSTRUCTION GUIDE ON THE REVERSE SIDE OF THE ORDER FORM FOR FURTHER DETAILS. All subscription orders are subject to the provisions of the stock offering.

 

NAMES ON ACCOUNTS    ACCOUNT NUMBER
  
  
  
  

Please Note: Failure to list all of your accounts may result in the loss of part or all of your subscription rights.

(10) Acknowledgment and Signature: I understand that this Order Form, with full payment and properly executed, must be received by Harvard Illinois Bancorp, Inc. no later than 5:00 p.m., Central Standard time, on ____________, 2009. Otherwise, this Order Form will be voidable. I agree that after receipt by Harvard Illinois Bancorp, Inc., this Order Form may not be modified or cancelled without Harvard Illinois Bancorp, Inc. consent, and that if withdrawal from a deposit account has been authorized above, the amount will not otherwise be available for withdrawal by me. Federal Regulations prohibit any person from transferring or entering into any agreement directly or indirectly to transfer the legal or beneficial ownership of conversion subscription rights, or the underlying securities to the account of another. Under penalty of perjury, I certify that (1) the Social Security or Tax ID information and all other information provided hereon are true, correct and complete, (2) I am purchasing solely for my own account, and there is no agreement or understanding regarding the sale or transfer of the shares, or my right to subscribe for shares, and (3) I am not subject to backup withholding tax [cross out (3) if you have been notified by the IRS that you are subject to backup withholding.] I acknowledge that this security is not a deposit or savings account, is not federally insured, and is not guaranteed by Harvard Illinois Bancorp, Inc., Harvard Savings Bank, or by the federal government. If anyone asserts that the shares of common stock are federally insured or guaranteed, or are as safe as an insured deposit, I should call the Office of Thrift Supervision’s Consumer Response Center at (800) 842-6929. I further certify that, before purchasing the common stock of Harvard Illinois Bancorp, Inc., I received the Prospectus dated __________, 2009.

The Prospectus that I received, dated ___________, 2009 contains disclosure concerning the nature of the common stock being offered by Harvard Illinois Bancorp, Inc. and describes, in the Risk Factors section of the Prospectus, the risks involved in the investment in this common stock, including, but not limited to, the following:

 

1. WILL FILL WITH FINAL RISK FACTORS

LOGOYOUR ORDER IS NOT VALID UNLESS SIGNED LOGO

ONE SIGNATURE REQUIRED, UNLESS SECTION (3b) OF THIS FORM INCLUDES ACCOUNTS REQUIRING MORE THAN ONE SIGNATURE TO AUTHORIZE WITHDRAWAL.

IF SIGNING AS A CUSTODIAN, CORPORATE OFFICER, ETC., PLEASE INCLUDE YOUR FULL TITLE

Signature (title, if applicable) ________________ (Date)_______     Signature (title, if applicable) ________________ (Date)_______

For Internal Use Only

REC’D ___/___ CHECK# _______ $_______ CHECK#________ $_______ BATCH # _____ ORDER # ______ CATEGORY ___


Harvard Illinois Bancorp, Inc.

Order Form Instructions

Item 1 and 2 - Fill in the number of shares that you wish to purchase and the total payment due. The amount due is determined by multiplying the number of shares ordered by the subscription price of $10.00 per share. The minimum purchase is 25 shares. Generally, the maximum purchase for any person is 10,000 shares (10,000 shares x $10.00 per share = $100,000). No person, together with “associates”, as defined in the prospectus, and persons “acting in concert”, as defined in the prospectus, may purchase more than 30,000 shares (30,000 shares x $10.00 per share = $300,000) of the common stock offered in the stock offering. For additional information, see “The Conversion; Plan of Distribution - Limitations on Common Stock Purchases” in the prospectus.

Item 3a - Payment for shares may be made in cash (only if delivered by you in person, although we request you to exchange the cash for a check with any of the tellers at our Harvard Savings Bank branches) or by check, bank draft or money order payable to Harvard Illinois Bancorp, Inc. DO NOT MAIL CASH. Your funds will earn interest at Harvard Savings Bank passbook savings rate until the stock offering is completed.

Item 3b - To pay by withdrawal from a deposit account or certificate of deposit at Harvard Savings Bank insert the account number(s) and the amount(s) you wish to withdraw from each account. If more than one signature is required for a withdrawal, all signatories must sign in the signature box on the front of the Stock Order form. To withdraw from an account with checking privileges, please write a check. Harvard Savings Bank will waive any applicable penalties for early withdrawal from certificate of deposit accounts (CDs). A hold will be placed on the account(s) for the amount(s) you indicate to be withdrawn. Payments will remain in account(s) until the Stock Offering closes and earn their respective rate of interest, but will not be available for your use until the completion of the transaction.

Item 4 - Please check the appropriate box to tell us the earliest of the three dates that apply to you, or the local community or general public boxes if you were not a depositor on any of the key dates.

Item 5 - Please check one of these boxes if you are a director, officer or employee of Harvard Savings Bank or Harvard Illinois Bancorp, Inc., or a member of such person’s household.

Item 6 - Please check the box, if applicable. If you check the box but have not subscribed for the maximum amount and did not complete Item 7, you may not be eligible to purchase more shares.

Item 7 - Check the box, if applicable, and provide the requested information. Attach a separate page, if necessary. In the Prospectus dated __________, 2009, please see the section entitled “The Conversion; Plan of Distribution - Limitations on Common Stock Purchases” for more information regarding the definition of “associate” and “acting in concert.”

Item 8 - The stock transfer industry has developed a uniform system of shareholder registrations that we will use in the issuance of Harvard Illinois Bancorp, Inc. common stock. Please complete this section as fully and accurately as possible, and be certain to supply your social security or Tax I.D. number(s) and your daytime and evening phone numbers. We will need to call you if we cannot execute your order as given. If you have any questions regarding the registration of your stock, please consult your legal advisor or contact the Stock Information Center at (            ) ________. Subscription rights are not transferable. If you are an eligible or supplemental eligible account holder or other depositor, to protect your priority over other purchasers as described in the prospectus, you must take ownership in at least one of the account holder’s names.

Individual - The stock is to be registered in an individual’s name only. You may not list beneficiaries for this ownership.

Joint Tenants - Joint tenants with rights of survivorship identifies two or more owners. When stock is held by joint tenants with rights of survivorship, ownership automatically passes to the surviving joint tenant(s) upon the death of any joint tenant. You may not list beneficiaries for this ownership.

Tenants in Common - Tenants in common may also identify two or more owners. When stock is to be held by tenants in common, upon the death of one co-tenant, ownership of the stock will be held by the surviving co-tenant(s) and by the heirs of the deceased co-tenant. All parties must agree to the transfer or sale of shares held by tenants in common. You may not list beneficiaries for this ownership.

Individual Retirement Account - Individual Retirement Account (“IRA”) holders may only make stock purchases from their existing IRA if it is a self-directed IRA or through a prearranged “trustee-to-trustee” transfer if their IRA is currently at Harvard Savings Bank. The stock cannot be held in your Harvard Savings Bank account. Please contact your broker or self-directed IRA account provider as quickly as possible to explore this option, as it may take several days to complete a trustee-to-trustee transfer.

 

Registration for IRA’s:    On Name Line 1 - list the name of the broker or trust department followed by CUST or TRUSTEE.
   On Name Line 2 - FBO (for benefit of) YOUR NAME [IRA a/c #______].
   Address will be that of the broker / trust department to where the stock certificate will be sent.
   The Social Security / Tax I.D. number(s) will be either yours or your trustee’s, as the trustee directs.
   Please list your phone numbers.

Uniform Transfers To Minors Act - For residents of Illinois and most states, stock may be held in the name of a custodian for the benefit of a minor under the Uniform Transfers to Minors Act (“UTMA”). For residents of South Carolina and Vermont, stock may be held in a similar type of ownership under the Uniform Gifts to Minors Act (“UGMA”) of the individual state. For either ownership, the minor is the actual owner of the stock with the adult custodian being responsible for the investment until the child reaches legal age. Only one custodian and one minor may be designated.

 

Registration for UTMA or UGMA:    On Name Line 1 – print the name of the custodian followed by the abbreviation “CUST”
   On Name Line 2 – FBO (for benefit of) followed by the name of the minor, followed by UTMA-IL
   (or your state’s abbreviation) or UGMA-SC (or your state’s abbreviation)
   List only the minor’s social security number on the form.

Corporation/Partnership - Corporations/Partnerships may purchase stock. Please provide the Corporation/Partnership’s legal name and Tax I.D. To have priority subscription rights, the Corporation/Partnership must have an account in the legal name. Please contact the Stock Information Center to verify subscription rights and purchase limitations.

Fiduciary/Trust - Generally, fiduciary relationships (such as Trusts, Estates, Guardianships, etc.) are established under a form of trust agreement or a court order. Without a legal document establishing a fiduciary relationship, your stock may not be registered in a fiduciary capacity.

Instructions: On the first name line, print the first name, middle initial and last name of the fiduciary if the fiduciary is an individual. If the fiduciary is a corporation, list the corporate title on the first name line. Following the name, print the fiduciary title, such as trustee, executor, personal representative, etc. On the second name line, print the name of the maker, donor or testator or the name of the beneficiary. Following the name, indicate the type of legal document establishing the fiduciary relationship (agreement, court order, etc.). In the blank after “Under Agreement Dated,” fill in the date of the document governing the relationship. The date of the document need not be provided for a trust created by a will.

Item 9 - You should list any qualifying accounts that you have or may have had with Harvard Savings Bank in the box located under the heading “Qualifying Accounts”. For example, if you are ordering stock in just your name, you should list all of your account numbers as of the earliest of the three dates that you were a depositor. Similarly, if you are ordering stock jointly with another depositor, you should list all account numbers under which either of you are owners, i.e. individual accounts, joint accounts, etc. If you are ordering stock in your minor child’s or grandchild’s name under the Uniform Transfers to Minors Act, the minor must have had an account number on one of the three dates and you should list only their account number(s). If you are ordering stock as a corporation, you need to list just that corporation’s account number, as your individual account number(s) do not qualify. Failure to list all of your qualifying deposit account numbers may result in the loss of part or all of your subscription rights.

Item 10 - Sign and date the form where indicated. Before you sign please read carefully and review the information which you have provided and read the acknowledgement. Only one signature is required, unless any account listed in section 3b of this form requires more than one signature to authorize a withdrawal. Please review the Prospectus dated ___________, 2009 carefully before making an investment decision.

Should you have any questions, please call our Stock Information Center at (            ) _________, Monday through Friday between 9:00 a.m. and 4:00 p.m., Central Time, except bank holidays.