SBM Certificate Company Certificate Application and Disclosure Statement

Summary

This document is an application form for individuals or entities seeking to purchase a certificate from SBM Certificate Company. Applicants provide personal, financial, and investment information, select the type and amount of certificate, and choose interest and beneficiary options. The form includes a substitute W-9 certification for tax purposes and requires signatures to confirm the accuracy of the information and agreement to the terms and conditions. Dealers or brokers may also complete a section to facilitate the purchase on behalf of the applicant.

EX-4.(A) 3 d59008_ex4-a.txt FORM OF APPLICATION Exhibit 4(a) [LOGO] SBM CERTIFICATE CO. 5101 River Road Suite 101 Bethesda, MD 20816 CERTIFICATE APPLICATION AND DISCLOSURE STATEMENT or P.O.Box 307 New Ulm, MN 56073 (Please complete one application for EACH certificate amount desired) Account No. __________ - ------------------------------------------------------------------------------------------------------------------------------------ GENERAL INFORMATION - ------------------------------------------------------------------------------------------------------------------------------------ Owners of Account: _________________________________________________________ ____________________________________________________ Name Date of Birth Social Security # _________________________________________________________ ____________________________________________________ Name Date of Birth Social Security # Mailing Address: __________________________________________________________ ____________________________________________________ Name Date of Birth Social Security # __________________________________________________________ ____________________________________________________ Street Home Phone __________________________________________________________ ____________________________________________________ Business Phone __________________________________________________________ ____________________________________________________ City State Zip Email - ------------------------------------------------------------------------------------------------------------------------------------ ACCOUNT [_] Individual ownership [_] Uniform Gifts/Transfer to Minors [_] Trust (date trust established) ________ REGISTRATION [_] Joints Tenants with Right Act in State of_______________ Names of Trustee or other administrator INFORMATION of Survivorship [_] IRA* [_] TRADITIONAL [_] ROTH _______________________________________ - -------------- [_] Tenants in Common [_] SEP/IRA* [_] TOD (transfer on Death) - Beneficiaries [_] Corporate ownership [_] Pension or Profit Sharing Plan* _______________________________________ [_] Partnership ownership [_] Community Property _______________________________________ *Additional paper work may be required - ------------------------------------------------------------------------------------------------------------------------------------ CLIENT PROFILE - ------------------------------------------------------------------------------------------------------------------------------------ Employer: ____________________________________________________________ Employer Address: ________________________________________ Title/Occupation: ____________________________________________________ __________________________________________________________ Spouses Name: __________________________________________________ Spouses Employer _________________________________________ Spouses Date of Birth _______________________ Spouses Social Security # _____________________ No. of Dependents. ___________________ Brokerage Accounts? (current or former) Firm's Names _______________________________________________________________________________ Investment Objectives __________________________________________________________________ Investment Experience: Mortgage ______________________________ Rent _________________________ Own _____________ Stocks _____________ Years _________ ------------------------------------------------------------------------- Bonds/CD ___________ Years _________ (check appropriate box for all three Mutual Funds _______ Years _________ Categories) $0- $25,000- $50,000- $100,000- $200,000- $500,000- Refuse to $24,999 49,000 99,000 199,000 499,000 or more Disclose Options ____________ Years _________ ------------------------------------------------------------------------- Annual Income (all Commodities ________ Years _________ Sources) ...... ------------------------------------------------------------------------- Other ______________ Years _________ Net Liquid Assets ........ ------------------------------------------------------------------------- Net Worth (excluding residence) .... ------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------ CERTIFICATE INFORMATION - ------------------------------------------------------------------------------------------------------------------------------------ I/We would like to purchase a certificate as indicated below: INITIAL INVESTMENT AMOUNT - $ _____________________ Series Type (Circle One) 503 505 507 510 DISBURSEMENT AMOUNT- $ ______________________________ If Annual or Quartely Interest Paid Out Rate: _____________________________________% APR BENEFICIARY (if desired)______________ SSN ____________%______ INTEREST OPTION (Circle one) Compound Quarterly Annually __________________________________________ SSN ____________%______ - ------------------------------------------------------------------------------------------------------------------------------------ Substitute W-9 Certification [_] US CITIZEN/RESIDENT Under penalties of perjury, I certify by signing below that: [_] NON-RESIDENT ALIEN (i) on this application, I provided you with my correct Taxpayer Identification Number; and [_] W-8 FORM ATTACHED (ii) I am not subject to backup withholding because; (a) I have not been notified by the IRS that I am subject to backup withholding due to under reporting of interest or dividends; or (b) the IRS has notified me that I am no longer subject to backup withholding. - ------------------------------------------------------------------------------------------------------------------------------------ I/We certify that the information on this page is accurate and complete. I/We agree to all the terms and conditions as stated on back of this application. - ------------------------------------------------------------------------------------------------------------------------------------ SIGNATURE OF APPLICANT (or Authorized Signatory) DATE SIGNATURE OF JOINT APPLICANT (if any) DATE - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Dealer Information ONLY Please establish the Account specified by the owner and purchase through SBM Certificate Company, general distributor, at the public offering price, shares which you are authorized to purchase from us for the owner. The owner is authorized to send any future payments directly to you for investment. Confirm each transaction to the owner and to us. We guarantee the genuineness of the owner's signature. We are a duly registered dealer and have a sales agreement with SBM Certificate Company. ________________________________________________________________ _______________________________________________________________ Dealer Name Representative's Name Number ________________________________________________________________ _______________________________________________________________ Address Address ________________________________________________________________ _______________________________________________________________ City State Zip Code City State Zip Code ________________________________________________________________ Authorized Signature of Broker/Dealer Date Representative's Phone Number (__________) ____________________ Cat # 001594 (08/97) - ------------------------------------------------------------------------------------------------------------------------------------

==================================================================================================================================== CERTIFICATE TERMS AND CONDITIONS If your application is accepted, the following terms and conditions will govern the face-amount certificate ("Certificate") that is issued for you. 1. DEFINITIONS The terms "you" and "your" refer to the owner of the Certificate; the terms "we," "us", our" and the "Company" refer to SBM Certificate Company. 2. FACE-AMOUNT The face-amount of your Certificate is the amount of your principal investment at the Effective Date, less any principal withdrawals and charges assessed against such withdrawals. 3. EFFECTIVE DATE We will credit your initial principal investment and issue your Certificate on the date we accept your application. 4. ADDITIONAL PRINCIPAL INVESTMENTS We do not accept additional principal investments under your Certificate. 5. MATURITY DATE Series 503, Series 505, Series 507 and Series 510 Certificates mature 30, 30, 28 and 30 years after their respective Effective Dates. On the Maturity Date, we will pay you the account value ("Account Value") of your Certificate. At any time, your Account Value equals your principal investment, plus all accrued interest, less any withdrawals previously assessed. 6. GUARANTEE PERIODS The Guarantee Periods for a Series 503, Series 505, Series 507, and Series 510 Certificates are three, five, seven and ten years, respectively. The interest rate on a Certificate is locked in for the Guarantee Period. You can surrender your Certificate at the end of its Guarantee Period and incur no charges . 7. INTEREST We will credit interest monthly on the amount of interest that accrues on your Account Value. Accrued interest will compound annually based on a 30-day month and a 360-day year. The minimum interest rate ("Minimum Interest Rate") that we will credit to your Certificate is 2.5% per year. The interest rate applicable to your Certificate will vary from Guarantee Period to Guarantee Period. The applicable interest rate for your initial Guarantee Period will be the rate in effect on the date we accept your application and receive your principal investment at our offices. For any subsequent principal investments made, we will apply the interest rate in effect for the current Guarantee Period in which you are invested. You will begin earning interest on the Effective Date of your Certificate. We will establish the interest rates applicable to your Certificate from time to time at our sole discretion, provided, however, that the interest rate for each Guarantee Period will never be less than the minimum interest rate of 2.5%. 8. WITHDRAWALS AND SURRENDER You may withdraw all or a portion of your original investment at any time. The Company assesses a withdrawal charge if you withdraw some or all of your account value prior to the end of your Certificate's Guarantee Period. A withdrawal charge will be assessed and charged to your remaining account value or, in the case of a complete surrender, the amount withdrawn, according to the following schedule: SALES CHARGE APPLIED TO AMOUNT WITHDRAWN YEAR OF GUARANTEE PERIOD .............. 1 2 3 4 5 6 7 8 9 10 -- -- -- -- -- -- -- -- -- -- Series 503 6% 6% 5% Series 505 8% 8% 7% 6% 5% Series 507 9% 9% 9% 8% 7% 6% 5% Series 510 10% 10% 10% 10% 10% 9% 8% 7% 6% 5% The minimum amount you may withdraw is $1,000. The minimum amount remaining must be at least $1,000. You may choose to have interest compounded or paid annually, and you must maintain at least $5,000 in your account if you chose to have interest paid quarterly. If the amount remaining are less than these minimums, you will receive your entire account value, less the withdrawal charge. 9. SURRENDER VALUE Upon surrender of your Certificate prior to its maturity, we will pay you your Certificate's surrender value ("Surrender Value"), which, at any time, equals your Account Value immediately prior to surrender, less any withdrawal charges assessable at the time of surrender. In no event will your Surrender Value be less than the minimum amount prescribed by Section 28 of the Investment Company Act of 1940, as amended (the "Act"). 10. LOANS You may borrow up to 50% of your Account Value for a term of up to 5 years or the Maturity Date of your Certificate, whichever is earlier. Loans are subject to an annual interest charge of up to 6% of the amount withdrawn, but are not subject to the withdrawal charge. You will not earn interest on the amount borrowed. We will treat a loan that you do not repay as a permanent withdrawal. We will assess the penalty for early withdrawal that would have applied at the time of withdrawal. 11. DEFERRED PAYMENT We may, at our option, defer any payment to you for a period of not more than 30 days and, in that event, interest shall accrue on any payment or payments due to you for the period of such deferment at the Minimum Interest Rate. 12. MAINTENANCE OF RESERVES Your Certificate is not secured by any particular asset of the Company. However, to support our obligations under your Certificate and all other Certificates that we issue, we maintain reserves in the amount and in assets of the type prescribed by the Act. For purposes of computing the reserves under your Certificate, the minimum maturity amount of your Certificate equals the face-amount of your Certificate, and no interest is payable or deemed payable until actually earned and credited. 13. EXCHANGING CERTIFICATES You may not exchange your Certificate for any other Certificate. 14. TRANSFERRING OWNERSHIP To transfer ownership of your Certificate, you must submit a completed transfer request form to us. 15. MISCELLANEOUS Your Certificate carries no voting rights and is not entitled to participate in any dividends that the Board of Directors may declare. The minimum and maximum amounts applicable to your principal investment(s) and withdrawals appear on your Certificate application. The minimum maturity or face-amount of your Certificate, your Account Value, your Surrender Value and other relevant data will appear on the periodic account statements that we will send to you. These account statements are incorporated herein to the extent necessary to comply with applicable law. 16. RECEIPT OF PROSPECTUS; SUITABILITY I have received, read, and agree to the terms of the current prospectus for each Certificate for which I am applying. I have the authority and legal capacity to purchase the Certificate(s), I am of legal age in my state, and believe each investment is suitable for me. 17. CANCELING MY ORDER I understand that I may cancel, without penalty, my investment in a Certificate within 10 days after the date of purchase. I understand that I will not earn any interest on any canceled Certificate. I also understand that it is the Company's policy to return my cancelled investment within 30 days of my cancellation request. 18. ACCEPTANCE OF APPLICATION I understand that acceptance of my application is at the sole discretion of SBM Certificate Company . 19. TELEPHONE INSTRUCTIONS I do ____ do not _______ authorize SBM Certificate Company, its affiliates and agents to act on any telephone instructions believed to be genuine. I understand that SBM Certificate Company will employ reasonable procedures to confirm that instructions communicated by telephone are genuine, and agree that if it does, neither it nor its affiliates and agents shall be liable for any claims, losses, or expenses (including legal fees) for acting on any instructions believed genuine. I acknowledge that all telephone instructions given pursuant to this authorization are subject to the conditions set forth in the prospectus for each Certificate. 20. FEES AND PENALTIES I understand that a withdrawal charge may apply for the Certificate that I purchase under the circumstances described in the prospectus. - ------------------------------------------------------------------------------------------------------------------------------------