Additional abbreviations may also be used though not in the above list.

EX-4.1 3 d744403dex41.htm EX-4.1 EX-4.1

Exhibit 4.1

FMSA

INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE

FMSA HOLDINGS INC.

SEE REVERSE FOR CERTAIN DEFINITIONS

CUSIP 30255X 10 6

IS THE RECORD HOLDER OF

FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK, $0.01 PAR VALUE PER SHARE, OF

transferable on the books of the Corporation in person or by his duly authorized attorney, upon surrender of this certificate properly endorsed.

This certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar. WITNESS the facsimile seal of the Corporation and the facsimile signatures of its duly authorized officers.

Dated:

VICE PRESIDENT, GENERAL COUNSEL AND SECRETARY

PRESIDENT, CHIEF EXECUTIVE OFFICER AND DIRECTOR

COUNTERSIGNED AND REGISTERED:

AMERICAN STOCK TRANSFER & TRUST COMPANY, LLC

TRANSFER AGENT

AUTHORIZED OFFICER

FMSA HoldingS inc.

THIS CERTIFIES THAT

By:

(Brooklyn, NY)

AND REGISTRAR

The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations:

 

TEN COM   

–

   as tenants in common    UNIF GIFT MIN ACT   

–

  

                     Custodian                     

     (Cust)                          (Minor)

under Uniform Gifts to Minors

Act                                                          

            (State)

TEN ENT   

–

   as tenants by the entireties        
JT TEN   

–

   as joint tenants with right of survivorship and not as tenants in common        

Additional abbreviations may also be used though not in the above list.

For value received,                                                                                                            hereby sell, assign and transfer unto

PLEASE INSERT SOCIAL SECURITY OR OTHER

IDENTIFYING NUMBER OF ASSIGNEE

 

    
 
      

 

PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING POSTAL ZIP CODE, OF ASSIGNEE

 

 

 

   Shares
of the Common Stock represented by the within Certificate, and do hereby irrevocably constitute and appoint

 

   Attorney

to transfer the Common Stock on the books of the within named Corporation with full power of substitution in the premises.

 

Dated                                         

 

   X     

 

   X     

 

 

     NOTICE: THE SIGNATURE(S) TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATEVER.

 

Signature(s) Guaranteed:   

 

 

   
THE SIGNATURE(S) MUST BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15.