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EXHIBIT 4.2
SPECIALTY MORTGAGE TRUST, INC.
COLLATERALIZED INVESTMENT NOTES
INVESTMENT APPLICATION
INDICATE TERM OF YOUR INVESTMENT
Enclosed is my check for the purchase of a Specialty Mortgage Trust,
Inc. collateralized investment note(s). I have received the Specialty Mortgage
Trust, Inc. prospectus and I am a bona-fide resident of the state listed below.
Call or write Specialty Mortgage Trust, Inc. if you want another prospectus.
Minimum investment is $25,000. Please invest my check in the amount of
$_______________ as follows:
$____ 1 month $____ 2 months $____ 4 months $____ 6 months
$____ 9 months $____ 12 months
INTEREST PAYMENT OPTION
Please check one of the following interest payment options:
____ Compound interest monthly and pay at maturity. If no interest
option is checked, interest will be compounded monthly and paid
at maturity.
____ Monthly (in arrears on the 20th day of each month)
INVESTOR INFORMATION
________________________________________________________________________________
Name of Account Owner (or First Joint Owner)
______________________________________________ ____________________________
Telephone Number (include area code) Date of Birth
________________________________________________________________________________
Street Address
__________________________ _________ ________________________
City State Zip Code
________________________________________________________________________________
Name of Joint Owner (if applicable)
________________________________________________________________________________
Name of Beneficiary
________________________________________________________________________________
Minor's name
Under the Nevada Uniform Transfer to Minors Act
INVESTOR EXPERIENCE
What types of investments have you made in the past? (Check all that
apply)
_____ Mutual Funds _____ Stocks & Bonds _____ Annuities
_____ Certificates of Deposit ______ Real Estate Trust Deeds
SIGNATURES
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<S> <C> <C> <C>
X___________________________________ _________ X_________________________________ _________
SIGNATURE OF ACCOUNT OWNER-- DATE JOINT SIGNATURE (IF APPLICABLE)-- DATE
ACCOUNT AUTHORIZATION ACCOUNT AUTHORIZATION
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MINIMUM INVESTMENT IS $25,000. MAKE YOUR CHECKS PAYABLE TO SPECIALTY MORTGAGE
TRUST, INC.
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PLEASE ANSWER THE FOLLOWING QUESTIONS:
How did you hear about Specialty Mortgage Trust, Inc.?
________________________________________________________________________________
________________________________________________________________________________
Would you like a brochure sent to a friend or family member who may be
interested in investing with Specialty Mortgage Trust, Inc.? If so, please
complete their name and address below.
________________________________________________________________________________
IF YOU HAVE NOT PREVIOUSLY INVESTED WITH SPECIALTY MORTGAGE TRUST, INC. PLEASE
COMPLETE THE TAX INFORMATION BELOW.
TAXPAYER IDENTIFICATION NUMBER (TIN) AND CERTIFICATION
Enter your TIN on the appropriate line below. For individuals, this is
your social security number (SSN). For joint accounts, the SSN of the account
owner (the first individual on the account) should be provided. For all other
types of accounts, see the chart below for guidelines on whose number to enter.
Social Security Number (SSN)___________________________________________ ; or
Employer Identification Number (EIN)___________________________________
PLEASE PRINT THE NAME OF THE PERSON/ENTITY WHOSE SSN OR EIN IS FURNISHED
ABOVE:_________________________________________________________________
Under penalty of perjury, I certify that: 1. The number shown on this form is
the correct applicable Taxpayer Identification Number (Social Security Number),
and 2. I am not subject to backup withholding either because I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends, or the
IRS has notified me that I am no longer subject to backup withholding. Only
cross out subpart 2 if you are subject to withholding.
The Internal Revenue Service does not require your consent to any provision of
this document other than the certification required to avoid backup withholding.
X___________________________________________________ ____________
SIGNATURE OF ACCOUNT OWNER -- TIN CERTIFICATION DATE
INSTRUCTIONS FOR TAXPAYER IDENTIFICATION NUMBER (TIN) AND CERTIFICATION
PURPOSE OF TIN AND CERTIFICATION. A company that is required to file an
information return with the IRS must get your correct TIN to report interest
income paid to you. GIVING YOUR CORRECT TIN AND MAKING THE APPROPRIATE
CERTIFICATION WILL PREVENT INTEREST PAYMENTS FROM BEING SUBJECT TO BACKUP
WITHHOLDING. WHAT IS BACKUP WITHHOLDING? Companies making certain payments to
you must withhold and pay to the IRS 31% of such payments under certain
conditions. This is called "backup withholding." Payments that could be subject
to backup withholding include interest payments. If you provide the correct TIN,
make the proper certifications, and report all your taxable interest, your
payments will not be subject to backup withholding.
WHAT TIN TO GIVE THE REQUESTER?
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FOR THIS TYPE OF ACCOUNT GIVE THE SOCIAL SECURITY NUMBER OF:
<S> <C>
1. Individual.......................................The individual
2. Joint Account....................................The account owner (i.e., the first individual on the account)
3. Custodian Account of a Minor.....................The minor
(Uniform Transfer to Minors Act)
4. In trust for account.............................The grantor and actual owner of the funds
5. Sole Proprietorship..............................The owner (note: employer identification number may be used instead)
FOR THIS TYPE OF ACCOUNT GIVE EMPLOYER IDENTIFICATION NUMBER OF:
6. A valid trust, estate or pension trust...........The legal entity
7. Corporate........................................The corporation
8. Unincorporated Association.......................The association
9. Partnership......................................The partnership
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