Attached files
| file | filename |
|---|---|
| S-1/A - FORM S-1/A - HIGHLANDS BANKSHARES INC /VA/ | forms-1ahbs05232014.htm |
| EX-99.7 - EX 99.7 - HIGHLANDS BANKSHARES INC /VA/ | hb99_7.htm |
| EX-5.1 - EX 5.1 OPINION OF WILLIAMS MULLEN - HIGHLANDS BANKSHARES INC /VA/ | hbi5_1.htm |
| EX-4.1 - EX 4.1 - HIGHLANDS BANKSHARES INC /VA/ | hbi4_1.htm |
| EX-99.1 - EX 99.1 - HIGHLANDS BANKSHARES INC /VA/ | hbi99_1.htm |
| EX-99.3 - EX 99.3 - HIGHLANDS BANKSHARES INC /VA/ | hbi99_3.htm |
| EX-23.1 - EX 23.1 CONSENT - HIGHLANDS BANKSHARES INC /VA/ | hbi23_1.htm |
| EX-99.5 - EX 99.5 - HIGHLANDS BANKSHARES INC /VA/ | hbi99_5.htm |
| EX-99.2 - EX 99.2 - HIGHLANDS BANKSHARES INC /VA/ | hbi99_2.htm |
| EX-99.4 - EX 99.4 - HIGHLANDS BANKSHARES INC /VA/ | hbi99_4.htm |
Exhibit 99.6
HIGHLANDS BANKSHARES, INC.
BENEFICIAL OWNER ELECTION FORM
The undersigned acknowledge(s) receipt of your letter and the enclosed materials relating to the grant of non-transferable rights to purchase common stock, par value $0.625 per share, of Highlands Bankshares, Inc. (the “Company”).
I (we) hereby instruct you as follows:
(CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION)
Box 1. q Please DO NOT EXERCISE RIGHTS for Shares.
Box 2. q Please EXERCISE RIGHTS for Shares as set forth below:
| A. Number of Shares Being Purchased: |
| B. Total Exercise Price Payment Required: |
Basic Subscription Right
| I exercise |
rights
|
|
x 1.00 =
|
|
|
|||
|
(no. of your rights)
|
|
(ratio)
|
|
|
(no. of Shares)
|
|||
|
Therefore, I apply for
|
|
|
x $3.50 =
|
|
|
|||
|
(no. of Shares)
|
|
(subscription price)
|
|
|
(amount enclosed)
|
|||
Over-Subscription Privilege
If you fully exercise your Basic Subscription Right, and wish to subscribe for additional shares up to the total number of unsubscribed shares, you may exercise your Over-Subscription Privilege. If sufficient shares are available, the Company will seek to honor the over-subscription requests in full. If, however, over-subscription requests exceed the number of unsubscribed shares, the Company will allocate the available shares pro rata among the shareholders exercising the Over-Subscription Privilege in proportion to the number of shares requested by such shareholders and the number of Unsubscribed Shares.
Accordingly, my maximum Over-Subscription Privilege is:
|
1,064,652
|
|
|
|
Shares
|
|||||
|
(total offered shares)
|
|
(total no. of shares subscribed for above)
|
|
|
(maximum unsubscribed shares)
|
||||
Therefore, I apply for:
|
x $3.50
|
||||
|
(no. of your over-
|
(subscription price)
|
|
||
| subscription shares subscribed for) | (additional amount enclosed) | |||
|
Total Payment Required =
|
$
|
|
Box 3. q Payment in the following amount is enclosed.
|
||
| $ |
|
|
(The total of the above Box 3 must equal the Total Payment Required.)
I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:
|
•
|
irrevocably elect to purchase the number of Shares indicated above upon the terms and conditions specified in the prospectus; and
|
|
•
|
agree that if I (we) fail to pay for the Shares I (we) have elected to purchase, the exercise will be invalid.
|
|
Name of Beneficial Owner(s):
|
||
|
Signature of Beneficial Owner(s):
|
||
|
State(s) of Residence of Beneficial Owner(s):
|
||
If you arc signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or another acting in a fiduciary or representative capacity, please provide the following information:
|
Name:
|
|
Capacity:
|
|
Address (including Zip Code):
|
||
|
Telephone Number:
|