EXHIBIT 4.3
METRIS COMPANIES INC.
[METRIS LOGO] Renewable Unsecured Subordinated Note Subscription Agreement
To purchase a renewable unsecured subordinated note(s), please complete this
form and send it along with your check and any other documents requested below
to the selling agent for the notes, Xxxxxx Xxxxxxxxxx Ltd., 00000 Xxxxxxx
Xxxxxxxxx, Xxxxx 000, Xxxxxxxxxxx, XX 00000. Make your check payable to METRIS
COMPANIES INC. If you have any questions, please call Xxxxxx Xxxxxxxxxx Ltd. at
000-000-0000.
NOTE PURCHASE AMOUNT (minimum principal amount $1,000 per note)
INTEREST PAYMENT SCHEDULE (please select one for each note)
Note Principal -------------------------------------------------------------------------------------
Term Amount Monthly* Quarterly Semi-Annually Annually Maturity
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Three Month $ |_| N/A N/A N/A |_|
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Six Month $ |_| |_| N/A N/A |_|
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One Year $ |_| |_| |_| |_| |_|
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Two Year $ |_| |_| |_| |_| |_|
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Three Year $ |_| |_| |_| |_| |_|
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Four Year $ |_| |_| |_| |_| |_|
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Five Year $ |_| |_| |_| |_| |_|
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Ten Year $ |_| |_| |_| |_| |_|
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TOTAL $ *Monthly interest payment date (e.g. 1st, 15th, etc.)
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FORM OF OWNERSHIP (please select one) |_| CUSTODIAN FOR A MINOR
|_| INDIVIDUAL INVESTOR (with optional beneficiary) |_| OTHER (please circle one)
|_| JOINT TENANTS WITH RIGHT OF SURVIVORSHIP XXX, SEP, 401(k), 403(b), Xxxxx, Trust, Corporation, Partnership
(Please include with this form a trust resolution or the appropriate
corporation or partnership documents authorizing you to make this
investment.)
NOTE PURCHASER (please circle one)
Full Name of Individual Investor/First Joint Tenant/Minor/Entity/Administrator/Trustee
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First Name Middle Name Last Name Social Security Number/Tax ID Number
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Date of Birth (if applicable)
Full Name of Beneficiary/Second Joint Tenant/Custodian (please circle one if applicable)
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First Name Middle Name Last Name Social Security Number/Tax ID Number
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Date of Birth (not required for custodians)
Other Metris Note Investors in my Family
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PRIMARY ADDRESS (Original correspondence will be sent to this address.)
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Individual Investor, XXX Administrator, Trustee, Custodian, Partnership, etc.
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Address
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City State Zip
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Daytime Phone (Include Area Code) E-mail Address
SECONDARY ADDRESS (Optional--copies of correspondence will be sent to this address.)
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Beneficiary, XXX Owner, Joint Tenant, Partner, etc.
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Address
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City State Zip
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Daytime Phone (Include Area Code) E-mail Address
DIRECT DEPOSIT Metris will electronically deposit your principal and interest
payments to either your checking or savings account. Please provide your direct
deposit information on the reverse side of this form.
PASSWORD When you call Xxxxxx Xxxxxxxxxx to discuss your investment, you may be
asked to verify your identification by answering the following question.
What is your mother's maiden name?_____________________________________________
CERTIFICATION Under penalties of perjury, I hereby declare and certify that: (i)
I am a bona fide resident of the state listed in the primary mailing address:
(ii) I have received and read the prospectus and all supplements provided by
Metris Companies Inc. and understand the risks associated with this investment;
(iii) the notes are an obligation of Metris Companies Inc. only and are not bank
certificates of deposit and are not guaranteed or insured by the FDIC or any
other entity; (iv) the social security number or tax identification number
listed above is correct; and (v) I am not subject to backup withholding, either
because the Internal Revenue Service has not notified me that I am subject to
backup withholding as a result of a failure to report all interest or dividends
or I have been notified that I am no longer subject to backup withholding. I
understand that my purchase offer is subject to the terms contained in the
prospectus and all supplements, may be rejected in whole or in part and will not
become effective until accepted by Metris Companies Inc. or its selling agent.
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Signature of Individual Investor/First Joint Tenant/Custodian/Authorized Person Date
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Signature of Second Joint Tenant (if applicable) Date
THE REVERSE SIDE OF THIS FORM MUST BE COMPLETED. OFFICE USE ONLY ACTP DATE
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METRIS COMPANIES INC.
Direct Deposit Form
PLEASE CHECK ONE
|_| I currently receive direct deposit payments from an existing Metris note.
Please deposit all principal and interest payments for this new note into
the same account.
|_| Please deposit my payments into the account listed below. (If this option
is chosen, the account owner must attach a VOIDED check -- or deposit slip
if this is a savings account -- to the bottom of this form.)
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Account Owner Name(s)
|_| Checking |_| Savings |_| Other
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Account Number
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Bank Routing Number (9 digits) Bank Name Branch Location
DIRECT DEPOSIT AUTHORIZATION
As the investor of record and authorized signatory of the account listed above,
I hereby authorize Metris Companies Inc., its affiliates, or its agents
(collectively hereinafter as "Metris") to deposit interest and principal
payments owed to me, by initiating credit entries in the account to my financial
institution listed on this form. Further, I authorize my financial institution
to accept and to credit any credit entries initiated by Metris to the listed
account. In the event of an erroneous credit entry, I also authorize Metris to
debit the account for an amount not to exceed the original amount of the
erroneous credit.
This authorization is to remain in full force and effect until Metris and my
financial institution have received written notice from me of its termination in
such time and in such manner as to afford Metris and my financial institution
reasonable opportunity to act on it. In the event the listed account is closed I
will promptly notify Metris of an alternate account into which payments can be
made.
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Authorized Signature Date
MAIL IN THE ENCLOSED POSTAGE-PAID ENVELOPE OR SEND TO:
XXXXXX XXXXXXXXXX LTD.
00000 Xxxxxxx Xxxx., Xxxxx 000
Xxxxxxxxxxx, Xxxxxxxxx 00000
ATTACH VOIDED CHECK OR SAVINGS ACCOUNT DEPOSIT SLIP HERE.
