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FSB
Community Bankshares, Inc. [logo]
Subscription
& Community Offering
Stock
Order Form
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Fairport
Savings Bank
Stock
Information Center
xxx
xxxxxx
xxxxx,
xx xxxxx
xxx-xxx-xxxx
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Expiration
Date
for
Stock Order Forms:
Xxxxxx,
June xx, 2007
_:00
p.m., Eastern time
(received
not postmarked)
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IMPORTANT:
A
properly completed original stock order form must be used to subscribe
for
common stock. Copies of this form are not required to be accepted.
Please
read the Stock Ownership Guide and Stock Order Form Instructions
as you
complete this form.
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(1)
Number of Shares
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Subscription
Price
X
10.00 =
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(2)
Total Payment Due
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Minimum
number of shares: 25 shares ($250.)
Maximum
number of shares: 10,000 shares ($100,000)
Maximum
number of shares for associates or group: 15,000 shares ($150,000)
See
Instructions.
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$
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(3)
Employee/Officer/Director Information
o
Check
here
if you are an employee, officer or director of Fairport Savings
Bank or
member of such person’s immediate family living in the same
household.
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(4)
Method of Payment by Check
Enclosed
is a check, bank draft or money order payable
to Fairport Savings Bank.
in
the amount indicated in this box.
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Total
Check Amount
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$
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.
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(5)
Method of Payment by Withdrawal - The
undersigned authorizes withdrawal from the following account(s)
at
Fairport Savings Bank. There is no early withdrawal penalty for
this form
of payment. Funds in an Individual Retirement Accounts maintained
at
Fairport Savings Bank cannot be used unless special transfer arrangements
are made.
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Bank
Use
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Account
Number(s) To Withdraw
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$
Withdrawal Amount
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$
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.
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$
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.
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(6)
Purchaser Information
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Subscription
Offering - Check here and list account(s) below if you
had:
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o
a.
A
deposit account(s) totaling $50 or more on the close of business
December
31, 2005 (“Eligible Account Holder”).
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o
b.
A
deposit account(s)
totaling $50 or more on the close of business March 31, 2007 but
are not
an Eligible Account Holder (Supplemental Eligible Account Holder).
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o
c.
A
deposit account(s) )
totaling $50 or more on the close of business April 30, 2007 or
a loan
outstanding as of January 14, 2005 that continued to be outstanding
as of April 30, 2007 but are not and Eligible Account Holder or
Supplemental Eligible Account (“Other Member”).
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Community Offering
-
Check here if you are:
o
d.
A
community member (Indicate county of residence in #9
below).
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PLEASE
NOTE: FAILURE TO LIST ALL YOUR ACCOUNTS MAY RESULT IN THE LOSS
OF PART OR
ALL OF YOUR SUBSCRIPTION RIGHTS. SEE REVERSE SIDE FOR ADDITIONAL
SPACE.
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Bank
Use
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Account
Number(s)
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Account
Title (Name(s) on Account)
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(7)
Form of Stock Ownership & SS# or Tax ID#:
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SS#/Tax
ID#
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²
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oIndividual
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oJoint
Tenants
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o
Tenants
in Common
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o
Fiduciary
(i.e., trust, estate)
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o
Uniform
Transfers to Minors Act (Indicate SS# of Minor only)
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o Company/Corporation/
Partnership
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o
IRA
or other qualified plan
(Both Tax ID# & SS# for IRAs)
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SS#/Tax ID#
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²
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(8)
Stock Registration & Address:
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Name
and address to appear on stock certificate.
Adding
the names of other persons who are not owners of your qualifying
account(s) will result in the loss of your subscription
rights.
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Name:
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Name
Continued:
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Mail
to-
Street:
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City:
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State:
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Zip
Code:
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(9)
Telephone
Daytime/Evening
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(
) --
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( ) --
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County
of
Residence
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(10)
o NASD
Affiliation
- Check
here if you are a member of the National Association of Securities
Dealers, Inc. (“NASD”), a person affiliated, or associated, with a NASD
member, (continued on reverse side)
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(11)
o Associates/Acting
in Concert
- Check
here and complete the reverse side of this form if you or any associates
or persons acting in concert with you have submitted other orders
for
shares.
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(12)
Acknowledgement - To
be effective, this stock order form must be properly completed
and
physically received (not postmarked) by Fairport Savings Bank no
later
than _:00 p.m., Eastern time, on Xxxxxx, June xx, 2007, unless
extended;
otherwise this stock order form and all subscription rights will
be void.
The undersigned agrees that after receipt by Fairport Savings Bank,
this
stock order form may not be modified, withdrawn or canceled without
Fairport Savings Bank’s consent and if authorization to withdraw from
deposit accounts at Fairport Savings Bank has been given as payment
for
shares, the amount authorized for withdrawal shall not otherwise
be
available for withdrawal by the undersigned. Under penalty of perjury,
I
hereby certify that the Social Security or Tax ID Number and the
information provided on this stock order form are true, correct
and
complete and that I am not subject to back-up withholding. It is
understood that this stock order form will be accepted in accordance
with,
and subject to, the terms and conditions of the stock issuance
plan of FSB
Community Bankshares, Inc. described in the accompanying prospectus.
The
undersigned hereby acknowledges receipt of the prospectus at least
48
hours prior to execution and delivery of this stock order form
to FSB
Community Bankshares, Inc.
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Federal
regulations prohibit any person from transferring, or entering
into any
agreement, directly or indirectly, to transfer the legal or beneficial
ownership of subscription rights or the underlying securities to
the
account of another. Fairport Savings Bank, FSB Community Bankshares,
Inc.
and FSB Community Bankshares, MHC will pursue any and all legal
and
equitable remedies in the event they become aware of the transfer
of
subscription rights and will not honor orders known by them to
involve
such transfer. Under penalty of perjury, I certify that I am purchasing
shares solely for my account and that there is no agreement or
understanding regarding the sale or transfer of such shares, or
my right
to subscribe for shares.
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Bank
Use
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Signature Date
²
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Signature Date
²
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Item
(6) Purchaser Account Information continued:
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Bank
Use
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Account
Number(s)
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Account
Title (Name(s) on Account)
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Item
(10) NASD continued:
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a
member of the immediate family of any such person to whose support
such
person contributes, directly or indirectly, or the holder of an
account in
which a NASD member or person associated with a NASD member has
a
beneficial interest. You agree, if you have checked the NASD Affiliation
box, to report this subscription in writing to the applicable NASD
member
within one day of payment therefor.
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Item
(11) Associates/Acting In Concert continued:
If
you checked the box in item #11 on the reverse side of this form,
list
below all other orders submitted by you or associates (as defined
below)
or by persons acting in concert with you (also defined
below).
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Name(s)
listed on other stock order forms
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Number
of shares ordered
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Associate
-
The term “associate” of a particular person means:
(1)
any
corporation or organization, other than FSB Community Bankshares,
MHC, FSB
Community Bankshares, Inc. or Fairport Savings Bank or a majority-owned
subsidiary of FSB Community Bankshares, Inc. or Fairport Savings
Bank, of
which a person is a senior officer or partner, or beneficially
owns,
directly or indirectly, 10% or more of any class of equity securities
of
the corporation or organization;
(2)
any
trust or other estate if the person has a substantial beneficial
interest
in the trust or estate or is a trustee or fiduciary of the estate.
For
purposes of Office of Thrift Supervision Regulations Sections 563b.370,
563b.380, 563b.385, 563b.390 and 563b.505, a person who has a substantial
beneficial interest in a tax-qualified or non-tax-qualified employee
plan,
or who is a trustee or fiduciary of the plan is not an associate
of the
plan. For purposes of Section 563b.370 of the Office of Thrift
Supervision
Regulations, a tax-qualified employee plan is not an associate
of a
person;
(3) any
person who is related by blood or marriage to such person and (i)
who
lives in the same house as the person; or (ii) who is a director
or senior
officer of FSB Community Bankshares, MHC, FSB Community Bankshares,
Inc.
or Fairport Savings Bank or a subsidiary thereof; and
(4)
any
person acting in concert with the persons or entities specified
above.
Acting
in concert-
The
term “acting in concert” means:
(1) knowing
participation in a joint activity or interdependent conscious parallel
action towards a common goal whether or not pursuant to an express
agreement; or
(2)
a combination or pooling of voting or other interests in the securities
of
an issuer for a common purpose pursuant to any contract, understanding,
relationship, agreement or other arrangement, whether written or
otherwise.
In
general, a person who acts in concert with another party will also
be
deemed to be acting in concert with any person who is also acting
in
concert with that other party.
We
may presume that certain persons are acting in concert based upon
various
facts, among other things, joint account relationships and the
fact that
persons may have filed joint Schedules 13D or 13G with the Securities
and
Exchange Commission with respect to other companies.
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YOU
MUST SIGN THE FOLLOWING CERTIFICATION IN ORDER TO PURCHASE
STOCK
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CERTIFICATION
FORM
I
ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT OR ACCOUNT AND
IS NOT
FEDERALLY INSURED OR GUARANTEED BY THE FEDERAL DEPOSIT INSURANCE
CORPORATION, AND IS NOT INSURED OR GUARANTEED BY FSB COMMUNITY
BANKSHARES,
MHC, FSB COMMUNITY BANKSHARES, INC., FAIRPORT SAVINGS BANK, THE
FEDERAL
GOVERNMENT OR BY ANY GOVERNMENT AGENCY. THE ENTIRE AMOUNT OF AN
INVESTOR’S
PRINCIPAL IS SUBJECT TO LOSS.
If
anyone asserts that this security is federally insured or guaranteed,
or
is as safe as an insured deposit, I should call Robert Albanese,
Regional
Director of the Northeast Regional Office of the Office of Thrift
Supervision at (201) 413-1000.
I
further certify that, before purchasing the common stock, par value
$0.10
per share, of FSB Community Bankshares, Inc. (the “Company”), the holding
company for Fairport Savings Bank, I received a prospectus of the
Company
dated __________ xx, 2007 relating to such offer of common
stock.
The
prospectus that I received contains disclosure concerning the nature
of
the common stock being offered by the Company and describes in
the “Risk
Factors” section beginning on page __, the risks involved in the
investment in this common stock, including but not limited to the
following:
Risks
Related to the Business
1.
Higher
Costs of Operations and Lower Interest Rate Margins Have Hurt Our
Profitability. If these Conditions Continue, We May Not Be Able
to Earn a
Profit During the Period Following Completion of the Stock
Offering.
2.
Our Lending Activities and Pricing Strategies for Loans and Deposits
Provide Us Lower Rates of Return than Financial Institutions that
Originate More Commercial Loans or Who are Less Aggressive in Pricing
Loan
and Deposit Products.
3.
The Current Interest Rate Environment Has Had and Will Have An
Adverse
Effect On Our Net Interest Income.
4.
Our
Operating Expenses are High as a Percentage of our Net Interest
Income,
Making It More Difficult to Maintain Profitability.
5.
Our
Growth Strategy Will Increase Our Expenses and May Not Be Successful.
6.
The Federal Deposit Insurance Corporation has Issued New Rules
that Will
Increase Our Deposit Insurance Assessments and Reduce Our Net
Income.
7.
Because Most of our Borrowers are Located in the Rochester, New
York
Metropolitan Area, a Downturn in the Local Economy or a Decline
in Local
Real Estate Values Could Cause an Increase in Nonperforming Loans,
Which
Could Hurt Our Profits.
8.
The Stock Offering Will Reduce Our Return on Average Equity.
9.
Strong Competition Within Our Market Areas May Limit Our Growth
and
Profitability.
10. If
Our Allowance for Loan Losses is Not Sufficient to Cover Actual
Loan
Losses, Our Earnings Will Decrease.
Risks
Related to the Stock Offering
11.
The
Future Price of the Shares of Our Common Stock May Be Less Than
the
Purchase Price in the Stock Offering.
12.
There
Will Be a Limited Trading Market in Our Shares of Common Stock,
Which Will
Hinder Your Ability to Sell Our Shares of Common Stock and May
Adversely
Affect the Market Price of the Stock.
13.
We
Will Need to Implement Additional Finance and Accounting Systems,
Procedures and Controls in Order to Satisfy Our New Public Company
Reporting Requirements, Which Will Increase our Operating
Expenses.
14.
Our
Stock-Based Benefit Plans Will Increase Our Costs, Which Will Reduce
Our
Income.
15.
Proposed
Office of Thrift Supervision Regulations May Permit Us to Adopt
Stock-Based Benefit Plans that Exceed Limits Applicable Under Current
Regulations, and May Permit us to Approve Stock Benefit Plans Without
a
Separate Vote of Minority Shareholders.
16.
The
Implementation of Stock-Based Benefit Plans May Dilute Your Ownership
Interest.
17.
We
Have Broad Discretion in Using the Proceeds of the Stock Offering.
Our
Failure to Effectively Use Such Proceeds May Reduce Our Net
Income.
18.
Persons
Who Purchase Stock in the Stock Offering Will Own a Minority of
Our Shares
of Common Stock and Will Not Be Able to Exercise Voting Control
Over Most
Matters Put to a Vote of Shareholders.
19.
Our
Stock Value May be Affected Negatively by Federal Regulations Restricting
Takeovers and Our Mutual Holding Company Structure.
20.
The
Corporate Governance Provisions in our Charter and Bylaws May Prevent
or
Impede the Holders of a Minority of Our Common Stock From Obtaining
Representation on Our Board of Directors.
21.
Office
of Thrift Supervision Policy on Remutualization Transactions Could
Prohibit the Acquisition of FSB Community Bankshares, Inc., Which
May
Lower Our Stock Price.
(By
Executing this Certification Form the Investor is Not Waiving Any
Rights
Under the Federal Securities Laws,
Including
the Securities Act of 1933 and the Securities Exchange Act of
1934)
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Signature Date
²
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Signature Date
²
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Print
Name
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Print
Name
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Stock
order and certification forms will only be
accepted by our subscription processor or, if delivered
by hand, at our
main office.
Your
order must be physically received (not postmarked)
by FSB Community Bankshares, Inc. no later than _:__ p.m., Eastern
time, on ___day, June __, 2007
Please
read the prospectus carefully before making in
investment decision.
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Stock
Ownership Guide
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Individual
Include
the first name, middle initial and last name of the shareholder.
Avoid the
use of two initials. Please omit words that do not affect ownership
rights, such as “Mrs.”, “Mr.”, “Dr.”, “special account”, “single person”,
etc.
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Joint
Tenants
Joint
tenants with right of survivorship may be specified to identify
two or
more owners. When stock is held by joint tenants with right of
survivorship, ownership is intended to pass automatically to the
surviving
joint tenant(s) upon the death of any joint tenant. All parties
must agree
to the transfer or sale of shares held by joint
tenants.
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Tenants
in Common
Tenants
in common may also be specified to identify two or more owners.
When stock
is held by tenants in common, upon the death of one co-tenant,
ownership
of the stock will be held by the surviving co-tenant(s) and by
the heirs
of the deceased co-tenant. All parties must agree to the transfer
or sale
of shares held by tenants in common.
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Uniform
Transfers to Minors Act (“UTMA”)
Stock
may be held in the name of a custodian for a minor under the Uniform
Transfers to Minors Act of each state. There may be only one custodian
and
one minor designated on a stock certificate. The standard abbreviation
for
Custodian is “CUST”, while the Uniform Transfers to Minors Act is “UTMA”.
Standard U.S. Postal Service state abbreviations should be used
to
describe the appropriate state. For example, stock held by John
Doe as
custodian for Susan Doe under the New Jersey Uniform Transfers
to Minors
Act will be abbreviated John Doe, CUST Susan Doe UTMA NY (use minor’s
social security number).
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Fiduciaries
Information
provided with respect to stock to be held in a fiduciary capacity
must
contain the following:
·
The
name(s) of the fiduciary. If an individual, list the first name,
middle
initial and last name. If a corporation, list the full corporate
title
(name). If an individual and a corporation, list the corporation’s title
before the individual.
·
The
fiduciary capacity, such as administrator, executor, personal
representative, conservator, trustee, committee, etc.
·
A
description of the document governing the fiduciary relationship,
such as
a trust agreement or court order. Documentation establishing a
fiduciary
relationship may be required to register your stock in a fiduciary
capacity.
·
The
date of the document governing the relationship, except that the
date of a
trust created by a will need not be included in the
description.
·
The
name of the maker, donor or testator and the name of the
beneficiary.
An
example of fiduciary ownership of stock in the case of a trust
is: John
Doe, Trustee Under Agreement Dated 10-1-93 for Susan
Doe.
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Stock
Order Form Instructions
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Items
1 and 2 - Number of Shares and Total Payment Due
Fill
in the number of shares that you wish to purchase and the total
payment
due. The amount due is determined by multiplying the number of
shares by
the subscription price of $10 per share. The minimum purchase in
the
subscription offering is $250 (25 shares) of common stock. As more
fully
described in the stock issuance plan outlined in the prospectus,
the
maximum purchase in any category of the subscription offering is
$100,000
(10,000 shares) of common stock, and the maximum purchase in the
community
offering (if held) by any person, is $100,000 (10,000 shares) of
common
stock. However, no person, together with associates and persons
acting in
concert with such person, may purchase in the aggregate more than
$150,000
(15,000 shares) of common stock.
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Item
3 - Employee/Officer/Director Information
Check
this box to indicate whether you are an employee, officer or director
of
Fairport Savings Bank or a member of such person’s immediate family living
in the same household.
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Item
4 - Method of Payment by Check
If
you pay for your stock by check, bank draft or money order, indicate
the
total amount in this box. Payment for shares may be made by check,
bank
draft or money order payable
to Fairport Savings Bank.
Payment in cash may be made only if delivered in person. Your funds
will
earn interest at Fairport Savings Bank’s passbook rate of interest until
the stock offering is completed.
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Item
5 - Method of Payment by Withdrawal
If
you pay for your stock by a withdrawal from a deposit account at
Fairport
Savings Bank, indicate the account number(s) and the amount of
your
withdrawal authorization for each account. The total amount withdrawn
should equal the amount of your stock purchase. There will be no
penalty
assessed for early withdrawals from certificate accounts used for
stock
purchases. This
form of payment may not be used if your account is an Individual
Retirement Account.
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Item
6 – Purchaser Information
Subscription
Offering
a.
Check this box if you had a deposit account(s) totaling $50.00
or more on the close of business December 31, 2005 (“Eligible Account
Holder”).
b. Check this box if you had a deposit account(s)
totaling $50.00 or more on the close of business March 31, 2007
but are
not an Eligible Account Holder (“Supplemental Eligible Account Holder”).
c. Check this box if you had a deposit account(s)
totaling $50.00 or more on the close of business April 30, 2007
or a loan
outstanding as of January 14, 2005 that continued to be outstanding
as of April 30, 2007 but are not and Eligible Account Holder or
Supplemental Eligible Account (“Other Member”). ***$50 requirement in
doc???????
Please
list all account numbers and all names on accounts you had on these
dates
in order to insure proper identification of your purchase
rights.
Note:
Failure to list all your accounts may result in the loss of part
or all of
your subscription rights.
Community
Offering
c.
Check this box if you are a community member (Indicate county of
residence
in item 9).
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Items
7 and 8 - Form of Stock Ownership, SS# or Tax ID#, Stock Registration
and
Mailing Address
Check
the box that applies to your requested form of stock ownership
and
indicate your social security or tax ID number(s) in item 7. Complete
the
requested stock certificate registration, mailing address in item
8. The
stock transfer industry has developed a uniform system of shareholder
registrations that will be used in the issuance of your common
stock. If
you have any questions regarding the registration of your stock,
please
consult your legal advisor. Stock ownership must be registered
in one of
the ways described above under “Stock Ownership Guide.” .” Adding
the names of other persons who are not owners of your qualifying
account(s) will result in the loss of your subscription
rights.
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Item
9 – Telephone Number(s) and County
Indicate
your daytime and evening telephone number(s) and county. We may
need to
call you if we have any questions regarding your order or we cannot
execute your order as given.
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Item
10 – NASD Affiliation
Check
this box if you are a member of the NASD or if this item otherwise
applies
to you.
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Item
11 – Associates/Acting in Concert
Check
this box if you or any associate or person acting in concert with
you (as
defined on the reverse side of the stock order form) has submitted
another
order for shares and complete the reverse side of the stock
form.
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Item
12 –
Acknowledgement
Sign
and date the stock order form and certification form where indicated.
Before you sign, review the stock order and certification form,
including
the acknowledgement. Normally, one signature is required. An additional
signature is required only when payment is to be made by withdrawal
from a
deposit account that requires multiple signatures to withdraw
funds.
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Your
stock order form, properly completed, signed certification form
and
payment in full (or withdrawal authorization) at the subscription
price
must be physically received (not postmarked) by FSB Community Bankshares,
Inc. no later than _:00 p.m., Eastern time, on Xxxxxx, June xx,
2007 or it
will become void.
Delivery
Instructions:
You
may deliver your stock order form by mail using the enclosed stock
order return envelope
or
by overnight
delivery
to
the stock information center address indicated on the front of
the stock
order form.
Hand
delivery
of stock order forms may be made only to the main office of Fairport
Savings Bank located
at 45 South Main St., Fairport, NY.
Stock
order forms will not be accepted at any of our branch
offices.
If
you have any remaining questions, or if you would like assistance
in
completing your stock order form, you may call our stock information
center at (xxx) xxx-xxxx, Monday
through Friday, between the hours of 10:00 a.m. and 4:00 p.m.,
Eastern
time.
Fairport
Savings Bank
Stock
Information Center
xxxxx
xxxxxxxxxxxxxxxxxx
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