[LOGO OF HFI APPEARS HERE] AGENCY AGREEMENT AND LIMITED POWER OF ATTORNEY
Hampshire Funding, Inc.
One Granite Place, P.O. Box 2005, Concord, NH 03302-2005
Check Applicable Box: __Original Agreement __Modification of Agreement
Subject to the agreement of Hampshire Funding, Inc. (the Company) I (We) (the
Participant(s)) hereby establish a Hampshire Funding, Inc. Program for the
Acquisition of Mutual Fund Shares and Insurance (the Program) which Program is
described in the Company's Prospectus (the Prospectus). This Agency Agreement
and Limited Power of Attorney (the Agreement) shall be governed by and
interpreted in accordance with the laws of the State of New Hampshire. Singular
nouns and pronouns shall be read in the plural, where applicable.
I hereby appoint the Company as my Agent and attorney-in-fact and assign and
transfer to the Company as my Agent all my interest in my investment account(s)
and in any future additions thereto which are or will be held pursuant to my
Program (hereinafter referred to as the Account) with open-end investment
companies registered under the Investment Company Act of 1940 (hereinafter
referred to as the Fund) and all shares of the Fund (hereinafter referred to as
the Shares), except the right to vote as a shareholder in all matters relating
to the Fund. The Account and Shares shall be held in the Company's name or in
that of its nominee as custodian for my Account, which shall be held pursuant to
the terms of this Agreement and the current Prospectus.
1. I hereby authorize the Company to make advances on my behalf to pay premiums
as they become due or excess premiums as agreed to by the Company, including
renewal premiums, on any insurance policy available through the Program for
which I have instructed the Company to pay the premiums, or on any policies
purchased to replace said policies.
This Agreement shall evidence my obligation to repay the advances as described
herein. I agree to pay the Company the amount of all such advances, including
interest at a per annum rate determined by the company, which may change at any
time during the Program but which at no time shall be less than the nominal
interest rate of 6% per annum nor more than 3 percentage points above the prime
or base rate as quoted in the Wall Street Journal; nor more than the maximum
rate permitted by the laws of the State of New Hampshire, which laws shall
govern all matters of interest and charges hereunder. Any change in the
interest rate made by the Company will become effective immediately without
prior notice to the Participants. Interest will be compounded monthly,
quarterly, semiannually or annually, which shall be determined by the frequency
of the premium advances, i.e. the premium payment mode for the policy. The
aggregate advances plus accrued interest is hereinafter
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referred to as the Account Indebtedness. I hereby pledge with and authorize the
Company to hold as custodian and pledge my Shares as collateral security for the
payment of the Account Indebtedness in accordance with the terms herein and
those of the current Prospectus. I understand and agree that if I do not pay
the accrued interest upon its due date, the due date of the subsequent premium,
the principal amount of my Account Indebtedness shall be increased by the amount
of all accrued interest, the intent being that interest not paid when due shall
be deemed thereafter to be principal and shall be treated in the same manner as
advances made for insurance premiums.
2. I authorize the Company as my attorney-in-fact to accept on my behalf and
acknowledge the receipt of disclosure statements for the extension of credit
under the applicable regulations of the Federal Truth-In-Lending Act, if any,
for subsequent delivery to me.
3. I further hereby authorize the Company to assign and transfer my Account
indebtedness, and any Shares pledged to the Company as required to secure such
Account Indebtedness as collateral security for the Company's indebtedness
pursuant to any financing arrangements with certain lenders, but only to the
extent of the Account Indebtedness plus the current premium or premiums of the
policies listed above. Such Account Indebtedness and the Shares pledged to
secure the Company's Indebtedness shall not exceed my Account Indebtedness and
the Shares pledged to the Company in accordance with the terms of the
Prospectus. I further understand that in the event any of my pledged Shares are
sold or redeemed pursuant to the terms of this Agreement, the Prospectus, or the
Company's financing arrangements, my financial responsibility will be limited by
the amount of my Account Indebtedness to the Company; that the proceeds of the
sale or redemption of any Shares in excess of my Account Indebtedness will be
paid to me as though I specifically requested withdrawal of the same, unless
investment thereof is directed by me in writing, via mail or facsimile, in which
event I understand: (i) regular investment charges, if any, will be charged
with respect to any purchase of additional Shares; (ii) the number of Shares so
sold or redeemed shall not exceed the number of full Shares the sale or
redemption value of which will provide cash equal to my Account Indebtedness
hereunder; and (iii) any pledged Shares not sold or redeemed to satisfy my
Account Indebtedness will be delivered to my Account and released from all
pledge arrangements contemplated hereby.
4. I understand that I may at any time elect to pay the interest on my Account
Indebtedness in cash or to prepay in cash my Account Indebtedness in full or in
part, provided that I pay fees and charges as stated in the Prospectus which is
current at the time of termination or payment of Account Indebtedness. If the
Account Indebtedness is prepaid in full, the Program and this Agreement will
terminate.
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Form 4-0701 Ed. 3/96 Page 1 of 3
5. I authorize the Company, as my attorney-in-fact, to execute on my behalf any
stock transfer power subject to the limitations stated herein and in the
Prospectus.
6. I agree to pay the Company annually an administrative charge which will
reasonably compensate it for its services pursuant hereto. Unless such
administrative charge is paid by me in cash, the Company, at its discretion,
hereby is further authorized to pay this charge by redeeming Shares in the
amount equal to such charge or to increase my Account Indebtedness by an amount
equal to that charge. I also understand that I may pay the entire
administrative charges over the life of the Program by paying, at the time this
Agreement is signed, a nonrefundable lump sum fee. I also agree to pay all
termination fees and liquidation charges upon termination of the Program and all
charges for special services in accordance with the current Prospectus.
7. This Appointment and Agreement may be terminated effective immediately by me
upon written notice mailed or transmitted via facsimile to the Company and will
be terminated by the Company upon the happening of any of the following events:
1) the death of all Participants of the Program; 2) the death of all Insureds
covered by a policy (ies) under the Program; 3) if the Shares held as collateral
for the Account Indebtedness fail to meet the minimum collateral requirements
due either to a decline in value of the Shares or an increase in the Account
Indebtedness as set forth in the Prospectus; 4) if the Program fails to meet the
Program's minimum investment requirements set forth in the Prospectus due to a
decrease in the insurance premiums advanced under the Program unless waived by
the Company to the extent permitted by law; 5) the date ten (10) years from the
due date of the initial premium advanced (Normal Expiration Date), unless
extended by mutual agreement between the Company and the Participant; or 6) upon
the inability of the Company to provide or arrange for financing of premiums.
If the Participant is a corporation, death of all Participants shall be read the
dissolution, or bankruptcy of the corporation or the appointment of a trustee or
receiver for its property; if a Trustee pursuant to a valid trust instrument,
the termination of the trust. Notwithstanding such termination, the
appointments made hereunder shall continue in effect for the purpose of
redeeming my Shares or otherwise effecting payment of my Account Indebtedness.
The Company, any lender, and the Fund shall be entitled to rely and act upon the
authority granted by me under this Agreement until each of them respectively has
received actual written notice of its revocation or termination.
8. I understand that the Company cannot give any assurance that the proposed
insured, in an application for a policy to be included in a Program, will
qualify for insurance. No fees charged at the initiation of a Program apply to
insurance, thus no conditional receipt for insurance coverage will be issued;
that is, I will be without
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insurance coverage until (i) the application for insurance is approved and (ii)
the expiration of 31 days from the date of purchase of the mutual fund shares.
If I wish to conditionally obtain insurance coverage prior to completion of the
underwriting process, I may pay an additional premium payment as described in
the current Prospectus. I understand that such conditional insurance coverage
may not be available in all cases.
9. Upon termination of this Agreement, the Program shall terminate and a
sufficient number of Shares held as collateral will be redeemed on a purely
discretionary basis by the Company to pay off the Account Indebtedness. The
remaining shares received from a pledgee or otherwise will be reregistered in
the name of the Participant. No investment of cash received in my Account upon
termination of this Agreement shall be made by the Company unless investment
thereof is directed by me in writing, in which event regular investment charges
will be made.
10. Subject to the agreement of the Company, the Participant in this Program
may be changed. The successor Participant must determine that the investment is
suitable for him/her and adopt all the terms of this Agreement as his/her own,
including the assumption of liability for the Account Indebtedness.
11. A policy may be added to the Program or the Program modified after its
inception upon agreement with the Company. However, the Program, if not
otherwise terminated, shall still terminate on the Normal Expiration Date,
unless extended by mutual agreement between the Company and the Participant.
12. The Program and all Shares held and/or purchased under the terms of a
Program for which there is more than one Participant will be held by Hampshire
Funding, Inc. as Custodian for all Participants as Joint Owners with rights of
survivorship, irrespective of the ownership of any shares prior to the
commencement of the Program.
Federal Reserve Board Regulation Z Disclosure Statement
All figures assume: 1) this Agreement will be in full force and effect until
the date ten (10) years from the due date of the initial premium advanced under
the Program, when the full amount of the loan (Account Indebtedness) will be
repaid; 2) the annual administrative charges are financed unless otherwise
indicated; 3) the interest rate, which is a variable rate and subject to change
at any time, remains the same throughout the ten year period of this Agreement;
and 4) no charges have been incurred for special services due to modification
of the Program. If premiums of a variable or dynamic life insurance policy are
paid under the Program, the amount and timing of payments are assumed to follow
the recommended payment schedule for the policy's current interest rate, which
is provided by the appropriate insurance
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company. These figures may change over the life of the Program, depending upon
deviations from the payment schedule,
Form 4-0701 Ed. 3/96 Page 2 of 3
changes in the policy's interest rate, which is variable, and the policy's face
amount.
1. Amount Financed, the amount of credit provided to you on your behalf
$__________.
2. FINANCE CHARGE, the dollar amount the credit will cost you
$_________________.
3. Total of Payments, the amount you will have paid when you have repaid the
loan $_______________.
4. ANNUAL PERCENTAGE RATE, the cost of your credit as a yearly rate. Excluding
annual administrative fee _____________. Including annual administrative fee
_____________.
You have the right to receive a written itemization of the Amount Financed. Do
you desire an itemization? __Yes __No
DEFAULT CHARGE: There are no default, delinquency or collection charges.
Reasonable fees will be charged for special services such as loan reductions,
protested checks, changes in frequency of advances, changes from one mutual fund
account to another, redemption of mutual fund shares, and others.
PREPAYMENT: A termination fee and liquidation charges will be imposed if the
Account Indebtedness is prepaid in full; reasonable fees also will be charged if
the loan balance is reduced. Refer to the terms of this Agreement and the
Prospectus which is current at the time of termination or payment of Account
Indebtedness for information regarding these fees and charges and relating to
default, your obligation to maintain adequate security, the right of Hampshire
Funding, Inc. to terminate the Program and require repayment of the Account
Indebtedness and any other transaction charges which may have been incurred.
VARIABLE RATE: The Annual Percentage Rate may increase or decrease at any time
during the term of the Program at the discretion of Hampshire Funding, Inc. The
nominal interest rate will in no event be less than 6% per annum nor exceed 3
percentage points above the prime or base rate as quoted in the Wall Street
Journal. An increase in the rate will mean a larger amount will be due upon
termination of the Program; additional collateral may be required in accordance
with the Margin Requirements of the Company. For example, if a Participant were
paying annual premiums of $1,000 at a nominal interest rate of 12.000% for the
ten year life of the Program, the Total of Payments, including the
administrative fee would be $20,833.86
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with an Annual Percentage Rate of 13.016%. If the Participant were paying the
same premium at a nominal interest rate of 13.000% for the ten year life of the
Program, the Total of Payments, including the administrative fee would be
$22,063.18 with an Annual Percentage Rate of 14.015%, rather than the figures
shown above. See the Prospectus for further details relating to the Margin
Requirements.
SECURITY: The Account Indebtedness is secured by the pledge of your Shares as
described in this Agreement and the current Prospectus.
CREDIT INSURANCE: Credit life and disability insurance are not required to
obtain credit.
MODIFICATION OF PROGRAM __ check box if applicable This Modification of
Program contains the Federal Reserve Board Regulation Z Disclosure Statement for
__addition of policy number(s)
__increase in premiums to be advanced due to modification of policy number(s)
in Hampshire Funding, Inc. Program No. _____________, established pursuant to an
Agency Agreement and Limited Power of Attorney executed by Hampshire Funding,
Inc. and ______________, on ___________, with an expiration date of
____________________.
I ACKNOWLEDGE, PRIOR TO THE CONSUMMATION OF THE TRANSACTION DISCLOSED HEREIN,
RECEIPT OF A COPY OF THIS AGREEMENT CONTAINING THE DISCLOSURES REQUIRED BY
FEDERAL LAW. I FURTHER ACKNOWLEDGE A COPY OF ALL APPLICABLE PROSPECTUSES (E.G.,
THE COMPANY PROSPECTUS, MUTUAL FUND PROSPECTUS AND VARIABLE PRODUCT PROSPECTUS).
I UNDERSTAND I WILL RECEIVE AN EXECUTED COPY OF THIS AGREEMENT AFTER IT HAS BEEN
COUNTERSIGNED BY THE COMPANY. I ALSO UNDERSTAND THAT I HAVE THE RIGHT TO
PURCHASE LIFE INSURANCE ONLY, EQUITY PRODUCTS ONLY, OR BOTH LIFE INSURANCE AND
EQUITY PRODUCTS SEPARATELY.
*Participant (1) SignsX Date Street Town State Zip
*Participant (2) SignsX Date Street Town State Zip
Hampshire Funding, Inc. xxxxxx accepts and agrees to act under the foregoing
Agency Agreement and Limited Power of Attorney. By: Date:
HAMPSHIRE FUNDING, INC. P.O. BOX 2005, Conncord, New Hampshire 03302
Form 4-0701 Ed. 3/96 Page 3 of 3
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