EX-99.6 12 ex99-6.txt Exhibit 99.6 FIDELITY FEDERAL BANCORP NOMINEE HOLDER CERTIFICATION The undersigned, a bank, broker, trustee, depositary or other nominee holder of subscription rights ("Rights") to purchase $1,000 principal amount notes ("Notes") or warrants ("Warrants") of Fidelity Federal Bancorp (the "Company") pursuant to the Rights Offering described and provided for in the Company's prospectus dated ________________, 2001 (the "Prospectus"), hereby certifies to the Company that: (1) the undersigned has exercised the number of Rights specified below pursuant to the Basic Subscription Right (as described in the Prospectus) and pursuant to the Basic Over-Subscription Privilege (as described in the Prospectus), on behalf of beneficial owners of Rights listing separately below each such exercised Basic Subscription Right and the corresponding Over-Subscription Privilege (without identifying any such beneficial owner); and (2) each such beneficial owner's Basic Subscription Privilege has been exercised in full if it is exercising its Over-Subscription Privilege.
Number of Number of Notes Number of Notes Number of Number of Warrants Shares Owned Subscribed Subscribed to Warrants subscribed Subscribed to on The Record Pursuant to Basic Pursuant to Basic to pursuant to the Pursuant to the Date Subscription Right Over-Subscription Warrant Warrant Over- Privilege Subscription Right Subscription Privilege 1. 2. 3. 4. 5.
____________________________________________________________ [Name of Bank, Broker, Trustee, Depositary or Other Nominee] By: _____________________________ Name: ___________________________ Title: ________________________