Exhibit 4.3


 








THE
TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE COMPANY’S PROSPECTUS DATED ________________, 2013 (THE
“PROSPECTUS”) AND ARE INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON REQUEST FROM CITIZENS
INDEPENDENT BANCORP, INC. AT (740) 385-8561. The Rights Offering expires at 5:00 p.m., Eastern Time, on ____________, 2013. Citizens
Independent Bancorp, Inc. (the “Company”) may extend the rights offering without notice to you until ____________,
2013 (such date and time, as it may be extended, the “Expiration Date”). RIGHTS CERTIFICATE NO. NUMBER OF RIGHTS REPRESENTED
BY THIS RIGHTS CERTIFICATE SEE REVERSE FOR CERTAIN DEFINITIONS Citizens Independent Bancorp, Inc. INCORPORATED UNDER THE LAWS
OF THE STATE OF OHIO REGISTERED OWNER: SUBSCRIPTION RIGHTS CERTIFICATE Evidencing Non-Transferable Rights to Purchase Common Shares
Subscription Price: $______ Per Share VOID IF NOT EXERCISED ON OR BEFORE THE EXPIRATION DATE The Company has distributed, at no
charge, to each holder of record of the Company’s common shares, no par value per share (“Common Share”), (each
a “Record Date Shareholder”), as of 5:00 Eastern Time on _______________, 2013 (the “Record Date”), one
subscription right (“Subscription Right”) for each Common Share held as of the close of business on the Record Date.
Each Subscription Right entitles a Record Date Shareholder to a Basic Subscription Privilege (the “Basic Subscription Privilege”)
and an Over-Subscription Privilege (the “Over-Subscription Privilege”). The Basic Subscription Privilege gives each
Record Date Shareholder the opportunity to purchase one Common Share at a subscription price of $_____ per share. Fractional Common
Shares resulting from the exercise of the Basic Subscription Privilege will be eliminated by rounding down to the nearest whole
share. In the event that a Record Date Shareholder purchases all of the Common Shares available pursuant to the Record Date Shareholder’s
Basic Subscription Privilege, the Record Date Shareholder may also choose to exercise an Over-Subscription Privilege, subject
to the Company’s acceptance of such subscription, reduction or proration and other limitations as described in the Prospectus,
to subscribe for a portion of any Common Shares that are not purchased by other Record Date Shareholders through the exercise
of their Basic Subscription Privilege. DATED: SECRETARY OF BOARD PRESIDENT AND CEO COUNTERSIGNED AND REGISTERED REGISTRAR AND
TRANSER COMPANY (CRANFORD, NJ) TRANSFER AGENT AND REGISTRAR BY AUTHORIZED SIGNATURE




 






    	 



    	 



    







 


DELIVERY OPTIONS FOR RIGHTS CERTIFICATE


 


DELIVERY OF THIS SUBSCRIPTION RIGHTS
CERTIFICATE TO AN ADDRESS OTHER THAN AS SET FORTH ABOVE DOES NOT CONSTITUTE A VALID DELIVERY


 


Delivery by facsimile will not constitute
valid delivery.


 


PLEASE PRINT ALL INFORMATION CLEARLY
AND LEGIBLY.


 


Method Of Exercise Of Rights


 


In order to exercise your Basic Subscription
Privilege and Over-Subscription Privilege, you must properly complete and sign this Rights Certificate in Section 2 below where
indicated and return it to the Subscription Agent, Registrar and Transfer Company, together with payment in full for an amount
equal to the subscription price multiplied by the total number of Common Shares subscribed for under your Basic Subscription Privilege
and Over-Subscription Privilege. To be timely, the Subscription Agent must receive the properly completed and executed Rights Certificate
and payment in full for the Common Shares subscribed for at or before 5:00 p.m., Eastern Time, on ____________, 2013, unless such
date is extended by the Company.


 


Full payment for the Common Shares subscribed
for pursuant to your Basic Subscription Privilege and Over-Subscription Privilege must be made payable in United States dollars
by wire transfer, personal check drawn on a U.S. bank, or certified check drawn on The Citizens Bank of Logan, Ohio, in each case
payable to “Registrar and Transfer Company.” You will not be paid any interest on funds paid to the Subscription Agent
regardless of whether the funds are applied to the subscription price or returned to you.


 


SECTION 1: EXERCISE AND SUBSCRIPTION:
The number of Subscription Rights represented by this Rights Certificate and the maximum number of Common Shares for which you
may subscribe under your Basic Subscription Privilege are set forth on the front of this Rights Certificate. Please see “
The Rights Offering—Limit on How Many Common Shares You May Purchase in the Stock Offering ” in the Prospectus
for a description of the purchase limits applicable to the Stock Offering. The undersigned hereby irrevocably exercises one
or more Subscription Rights to subscribe for Common Shares as indicated below, on the terms and subject to the conditions specified
in the Prospectus.


 


Step 1—Basic Subscription
Privilege


I wish to exercise my full Basic Subscription Privilege or a
portion thereof as follows:


 


	Number of	 	 	 	 	 	 
	Common Shares	 	 	 	 	 	Payment Due
	Subscribed for	 	 	 	 	 	Under Basic
	Under Your Basic	 	 	 	 	 	Subscription
	Subscription Privilege	 	 	Subscription Price	 	 	Privilege
	 	 	 	 	 	 	 
	 	×	 	 	 	 	 
	 	 	$	 	=	$	 


 


Step 2—Over-Subscription
Privilege


 


I have exercised my full Basic Subscription Privilege and in
addition to my full Basic Subscription Privilege I wish to subscribe for additional shares under my Over-Subscription Privilege
as follows:


 


	Number of	 	 	 	 	 	 
	Common Shares	 	 	 	 	 	Payment Due
	Subscribed for	 	 	 	 	 	Under Over-
	Under Your Over-	 	 	 	 	 	Subscription
	Subscription Privilege*	 	 	Subscription Price	 	 	Privilege
	 	 	 	 	 	 	 
	 	×	$	 	=	$	 


 


		*	The maximum
number of Common Shares you may subscribe for under your Over-Subscription Privilege is subject to the 9.9% of the total outstanding
limitation.


 


Step 3—Total Shares and Total Amount Enclosed


 


	 	 	 	 	 	 	Total Amount
	Total Shares:	 	 	Subscription Price	 	 	Enclosed:
	 	 	 	 	 	 	 
	 	×	$	 	=	$	 
	 	 	 	 	 	 	 
	Number of Common Shares	 	 	 	 	 	Total Payments Due
	Subscribed for under Basic	 	 	 	 	 	under Basic Subscription
	Subscription Privilege (Step 1) plus	 	 	 	 	 	Privilege (Step 1) plus
	Over-Subscription Privilege (Step 2)	 	 	 	 	 	Over- Subscription Privilege
	 	 	 	 	 	 	(Step 2)


 


I certify that the purchase of Common
Shares pursuant to the Subscription Rights (basic or over-subscription)               
 will  OR                will not
result in my (our) owning either directly or indirectly, of record or beneficially, more than ___________ Common Shares.


 


SECTION 2: SUBSCRIPTION AUTHORIZATION:
I acknowledge that I have received the Prospectus for this offering of Subscription Rights and I hereby irrevocably subscribe
for the number of Common Shares indicated above on the terms and conditions set forth in the Prospectus.


 


Signature of Subscriber(s)





 


	 
	 	 
	 



 


	 	 
	(address if different than that listed	 
	on this Rights Certificate)	 
	 	 
	Telephone number	 
	(including area code)	 


 


SECTION 3: SPECIAL ISSUANCE INSTRUCTIONS
(IF YOU COMPLETE THIS SECTION, YOU MUST ALSO COMPLETE SECTIONS 4 AND 5): The Subscription Rights are not transferable in any
way, except by operation of law. By executing below, you hereby represent and warrant that the person in whose name you are requesting
that we issue the Common Shares is a transferee by operation of law. Evidence satisfactory to the Company that any such permitted
transfer is proper must be delivered by mail, hand, express mail or overnight courier to Registrar and Transfer Company at the
address specified above prior to the Expiration Date.


 





Complete the following ONLY if the Common
Shares subscribed for are to be issued in a name other than that of the registered holder







 





	Issue Shares to:	 	 


 


	Soc. Sec. #/Tax ID#:	 	 
	 	 	 



 


	Address:	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 







  


SECTION 4: ACKNOWLEDGMENT (TO BE COMPLETED
ONLY IF YOU COMPLETED SECTION 3. IF YOU COMPLETE THIS SECTION, YOU MUST ALSO COMPLETE SECTION 5): I/We acknowledge receipt
of the Prospectus and understand that, after delivery to Registrar and Transfer Company as Subscription Agent, I/we may not modify
or revoke this Rights Certificate. Under penalties of perjury, I/we certify that the information contained herein, including the
social security number or taxpayer identification number given above, is correct.


 





The signature below must correspond with
the name of the registered holder exactly as it appears on the books of the Company’s transfer agent without any alteration
or change whatsoever







 


	Signature(s) of	 
	Registered Holder:	 
	 	 
	 	 
	 	 
	Date:                                     	 


 


If signature is by trustee(s), executor(s), administrator(s),
guardian(s), attorney(s)-in-fact, agent(s), officer(s) of a corporation or another acting in a fiduciary or representative capacity,
please provide the following information (please print).


 


	Name: 	 	 	Capacity:	 


 


	Soc. Sec. #/Tax ID #:	 	 


 


	Address: 	 	 	Phone:	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 


 


SECTION 5: GUARANTEE OF SIGNATURES (TO BE COMPLETED ONLY
IF YOU COMPLETED SECTIONS 3 AND 4): All Subscription Right holders who specify special issuance or delivery instructions must
have their signatures guaranteed by an Eligible Guarantor Institution, as defined in Rule 17Ad-15 of the Securities Exchange Act
of 1934, as amended.


 


	Name of Firm:	 


 


	Authorized Signature: 	 


 


	Address:	 	 	Name:	 


 


	 	 	 	 
	 	 	 	 
	 	 	Title:	 


 


	City, State, Zip Code:	 
	 	 
	 	 


  


	Area Code and Telephone Number:  	 


 


Any questions regarding this Rights Certificate
or submitting payments in the Rights Offering may be directed to Registrar and Transfer Company at (800) 368-5948 or info@rtco.com.


  


You are advised to review the Prospectus and the Instructions
as to Use of Citizens Independent Bancorp, Inc. Rights Certificates included with this Rights Certificate. Additional copies of
these materials may be obtained from the Company by calling ___________________ at (740) 385-8561.