EXHIBIT 4(a)
PRESS FIRMLY ON APPLICATION TO ENSURE LEGIBILITY OF ALL COPIES
FORM OF
SBM Certificate Company Certificate Application
[Logo SBM Certificate Company]
Sales Representative -----------------
Date --------------------------------- Application Type [ ] New [ ] Amended
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Personal Profile
APPLICANT
Name ------------------------------------------------------------------------
Address ---------------------------------------------------------------------
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E-Mail Address --------------------------------------------------------------
Marital Status ------------------- Tax ID # ---------------------------------
Date of Birth (m/d/y) -------------------------------------------------------
Citizenship [ ] U.S. Citizen [ ] Non-U.S. Citizen
Telephone Home (-----)------------------------------------------
Numbers Business (-----)------------------------------------------
Fax (-----)------------------------------------------
Occupation ------------------------------------------------------------------
Employer --------------------------------------------------------------------
Employer Address ------------------------------------------------------------
Spouse's Name ---------------------------------------------------------------
Spouse's Employer
(if client unemployeed) -----------------------------------------------------
Primary Bank Address --------------------------------------------------------
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JOINT APPLICANT
Name ------------------------------------------------------------------------
Address ---------------------------------------------------------------------
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E-Mail Address --------------------------------------------------------------
Marital Status ------------------- Tax ID #----------------------------------
Date of Birth (m/d/y)--------------------------------------------------------
Relationship to Applicant ---------------------------------------------------
Citizenship [ ] U.S. Citizen [ ] Non-U.S. Citizen
Telephone Home (-----)------------------------------------------
Numbers Business (-----)------------------------------------------
Fax (-----)------------------------------------------
Occupation ------------------------------------------------------------------
Employer --------------------------------------------------------------------
Employer Address ------------------------------------------------------------
Spouse's Name ---------------------------------------------------------------
Spouse's Employer
(if client unemployeed)------------------------------------------------------
Primary Bank Address --------------------------------------------------------
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Ownership
Type of ownership (check one).
[ ] Individual
[ ] Joint Tenants with right of survivorship
[ ] Tenants by the entirety
(Available only in AR, DE, DC, FL, HI, MD, MA, MI, MO, PA, TN, VT, WY)
[ ] Other -------------------------------------------------------------------
(Trust Corporate, UGMA, UTMA)
[ ] Tenants in common. Complete the following for each participant:
NAME OF INTEREST IN
PARTICIPANT THE ACCOUNT
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DEPENDENT(S):
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FIRST NAME
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DATE OF BIRTH (m/d/y)
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Name of CPA ------------------------------------------------------------------
Name of Attorney -------------------------------------------------------------
Do You Have A Will? [ ] yes [ ] no
CURRENT ASSETS
Savings $------------------------------------------------
Certificates of Deposit $------------------------------------------------
Money Market Funds $------------------------------------------------
Municipal Bonds $------------------------------------------------
Mutual Funds $------------------------------------------------
Stocks $------------------------------------------------
Real Estate $------------------------------------------------
Annuities $------------------------------------------------
Options $------------------------------------------------
Collectables $------------------------------------------------
Life Ins. (cash value) $------------------------------------------------
Qualified Retire. Plans $------------------------------------------------
RETIREMENT PLAN
[ ] IRA [ ] 403(b)
[ ] SEP/SARSEP [ ] -----------------------------------------
[ ] 401(k) [ ] -----------------------------------------
[ ] Profit Sharing [ ] -----------------------------------------
[ ] Qualified Pension Plan
[ ] Money Purchase Plan
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Objective
Investment Objective (Please select one):
[ ] Preservation of capital [ ] Income [ ] Income & Growth
[ ] Long-Term Growth
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Financial Profile
Approx. annual earnings (,000)
[ ] $500
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Total annual income (all sources (,000)
[ ] $500
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Approx. liquid net worth (,000)
[ ]<$100 [ ]$101-$499 [ ]$500-$999 [ ]$1,000-$5,000 [ ]$5,000-$9,999
[ ]>$10,000
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Approx. total net worth (,000)
[ ]<$100 [ ]$101-$499 [ ]$500-$999 [ ]$1,000-$5,000 [ ]$5,000-$9,999
[ ]>$10,000
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Certificates
Series 503 Certificate [ ]
Series 505 Certificate [ ]
Series 507 Certificate [ ]
Series 510 Certificate [ ]
Principal Investment $--------------------------------------------------------
(Minimum $1,000; Minimum $5,000 for quarterly interest)
Please indicate how interest income is to be disbursed:
[ ]Compound [ ]Paid Annually [ ]Paid Quarterly
[ ]Paid Monthly
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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), am of legal age in my
state, and believe each investment is suitable for me.
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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 canceled
investment within 30 days of my cancellation request.
ACCEPTANCE OF APPLICATION
I understand that acceptance of my application is at the sole discretion
of SBM Certificate Company and that you may reject my application for
any reason.
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.
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Applicant's Signature Joint Applicant's Signature
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W-9 Certification
Substitute W-9 Certification
Under penalties of perjury, I certify by signing below that:
(i) On this application, I provided you with my correct Taxpayer
Identification Number; and
(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 dividents; or
(b) the IRS has notified me that I am no longer subject to backup
withholding
I certify that the information on this page is accurate and complete. I agree
to be bound by the terms and conditions on the reverse side of this page.
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RETURN TO SBM Certificate Company
REPRESENTATIVE CERTIFICATION
By signing below, the Registered Rep/ Agent certifies that:
(a) The questions contained in this application were asked of the
applicant and the answers duly recorded: that this application is
complete and true to the best of my knowledge and belief;
(b) and I am NASD registered and state licensed for Investment Company
Products where this application is written and delivered;
(c) Clients provided $-------------------- as the initial purchase
payment.
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Representatives Name (Please Print) Name of Broker/ Dealer
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Representative's Signature Representative's Phone #
Application accepted by SBM Certificate Company: ----yes ---- no
By:-----------------------------------
Authorized Officer
SBM Certificate Company
CERTIFICATE TERMS AND CONDITIONS
If we accept your application, the following terms and conditions will
govern the face-amount certificate ("Certificate") that we issue to you.
1. DEFINITIONS
As used herein, 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.
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2. FACE-AMOUNT
The face-amount of your Certificate equals the amount of your principal
Investment at the Effective Date or at the time of a new Guarantee
Period.
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
investments, plus all accrued interest, less any withdrawals previously
taken and less applicable fees, charges and penalties 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 deferred sales or surrender charges and no
reduced interest rate.
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.
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We will establish the interest rates applicable to your Certificate from
time to time in 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. Any amounts you withdraw before the end of the Certificate's
Guarantee Period will earn a reduced rate of interest that the Company
predeclares.
The Company assesses a deferred sales 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 3% 3% 2%
Series 505 5% 5% 4% 3% 2%
Series 507 7% 7% 6% 5% 4% 3% 2%
Series 510 10% 10% 9% 8% 7% 6% 5% 4% 3% 2%
The minimum amount you may withdraw is $1,000. The minimum amount
remaining must be at least $1,000, if you chose to have interest
compounded to maturity or paid annually, and at least $5,000 if you
chose to have interest paid quarterly. If the amount remaining would
be less than these minimums, you will receive your entire account
value, less the deferred sales 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 applicable fees and 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
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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 a
transfer request form to us.
15. MISCELLANEOUS
Your Certificate carries no voting rights and is not entitled to
participate in any dividends that our 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.
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