----

| Insurer:                                                            |                 |   |
|---------------------------------------------------------------------|----------------------|--------|
|                                                                |                 |   |
|                                                                |                 |   |
| Policy      Number:                                                 |                 |   |
|                                                                |                 |   |
|                                                                |                 |   |
| Bank:                                                               | Bank      of Upson   |   |
|                                                                |                 |   |
| Insured:                                                            | Trae      D. Dorough |   |
|                                                                |                 |   |
| Relationship      of Insured to Bank:      | Officer              |   |

| I. | DEFINITIONS |
|----|-------------|

| II. | POLICY      TITLE AND OWNERSHIP |
|-----|---------------------------------|

| III. | BENEFICIARY      DESIGNATION RIGHTS |
|------|-------------------------------------|

----

| IV. | PREMIUM      PAYMENT METHOD |
|-----|-----------------------------|

| V. | TAXABLE      BENEFIT |
|----|----------------------|

| VI. | DIVISION      OF DEATH PROCEEDS |
|-----|---------------------------------|

|   | A. | Should      the Insured be employed by the Bank or retired from the bank at the time      of death, the Insured’s beneficiary(ies), designated in accordance with      Paragraph III, shall be entitled to an amount equal to the lesser of Two      Hundred Fifty Thousand and 00/100th      Dollars ($250,000.00) or eighty percent (80%) of the net-at-risk insurance      portion of the proceeds.  The net-at-risk insurance portion is      the total proceeds less the cash value of the  policy. |
|--------|----|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | B. | Should      the Insured not be employed by the Bank at the time of death, the Insured’s      beneficiary(ies), designated in accordance with Paragraph III, shall be      entitled to the percentage as set forth hereinbelow of the proceeds      described in Subparagraph VI (A) above that corresponds to the Insured’s      age: |
|--------|----|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| Age of the      Insured | Vested (to a maximum      of 100%)     |
|-------------------------|----------------------------------------|
| 59      and under       | 0%                                     |
| Age      60             | 50%                                    |
| 61-65                   | An      additional 10% vested per year |
|                    | (to      a total maximum of 100%)      |

|   | C. | The      Bank shall be entitled to the remainder of such  proceeds. |
|--------|----|---------------------------------------------------------------------|

|   | D. | The      Bank and the Insured (or assignees) shall share in any interest due on the      death proceeds on a pro rata basis as the proceeds due each respectively      bears to the total proceeds, excluding any such  interest. |
|--------|----|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

----

| VII. | DIVISION      OF THE CASH SURRENDER VALUE OF THEPOLICY |
|------|--------------------------------------------------------|

| VIII. | PREMIUM      WAIVER |
|-------|---------------------|

|   | If      the policy contains a premium waiver provision, such waived amounts shall      be be considered for all purposes of this Agreement as having been paid by      the Bank. |
|--------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

| IX. | RIGHTS      OF PARTIES WHERE POLICY ENDOWMENT OR ANNUITY ELECTION    EXISTS |
|-----|-----------------------------------------------------------------------------|

| X. | TERMINATION      OF AGREEMENT |
|----|-------------------------------|

|   | A. | This      Agreement shall terminate at the option of the Bank following thirty (30)      days written notice to the Insured upon the happening of any one of the      following: |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | 1. | The      Insured shall leave the employment of the Bank (voluntarily or      involuntarily) prior to the Insured attaining the age of sixty (60);      or |
|--------|----|-----------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | 2. | The      Insured shall be discharged from employment with the Bank for      cause.  The term “for cause” shall mean: (i) gross negligence or      neglect in the performance of his job; (ii) the commission of a felony or      gross misdemeanor involving fraud, dishonesty or willful violation of any      law that results in any adverse effect on the  Bank. |
|--------|----|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | B. | Upon      such termination of this Agreement but prior to the termination of the      policy by the Bank, the Insured (or assignee) shall have a fifteen (15)      day option to receive from the Bank an absolute assignment of the policy      in consideration of a cash payment to the Bank, whereupon this Agreement      shall terminate.  Such cash payment referred to hereinabove      shall be the greater of: |
|--------|----|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

----

|   | 1. | The      Bank’s share of the cash value of the policy on the date of such      assignment, as defined in this Agreement;or |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------|

|   | 2. | The      amount of the premiums that have been paid by the Bank prior to the date      of such assignment. |
|--------|----|------------------------------------------------------------------------------------------------------------|

|   | C. | Should      the Insured (or assignee) fail to exercise this option within the      prescribed fifteen (15) day period, the Insured (or assignee) agrees that      all of his rights, interest and claims in the policy shall terminate as of      the date of the termination of thisAgreeement. |
|--------|----|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | D. | In      the event, however, that the Insured is terminated “for cause” under the      terms as set forth in Subparagraph X (A) (2) above, the Bank shall have      the right, in its sole discretion, to allow the Insured to exercise the      option as set forth above. |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | E. | Except      as provided above, this Agreement shall terminate upon distribution of the      death benefit proceeds in accordance with Paragraph VI    above. |
|--------|----|--------------------------------------------------------------------------------------------------------------------------------------------------------------|

| XI. | INSURED’S      OR ASSIGNEE’S ASSIGNMENT RIGHTS |
|-----|------------------------------------------------------------|

| XII. | AGREEMENT      BINDING UPON THE PARTIES |
|------|-----------------------------------------|

| XIII. | ADMINISTRATIVE      AND CLAIMS PROVISIONS |
|-------|-------------------------------------------|

|   | A. | Plan      Administrator: |
|--------|----|--------------------------|

----

|   | B. | Basis of Payment of      Benefits: |
|--------|----|------------------------------------|

|   | C. | Claim      Procedures: |
|--------|----|------------------------|

| XIV. | GENDER |
|------|--------|

| XV. | INSURANCE      COMPANY NOT A PARTY TO THISAGREEMENT |
|-----|-----------------------------------------------------|

----

| XVI. | CHANGE      OF CONTROL |
|------|------------------------|

|   | a. | the      acquisition of more than fifty percent (50%) of the value or voting power      of the Bank’s stock by a person orgroup; |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------------|

|   | b. | the      acquisition in a period of twelve (12) months or less of at least      thirty-five percent (35%) of the Bank’s stock by a person or      group; |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | c. | the      replacement of a majority of the Bank’s board in a period of twelve (12)      months or less by Directors who were not endorsed by a majority of the      current board members; or |
|--------|----|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

|   | d. | the      acquisition in a period of twelve (12) months or less of forty percent      (40%) or more of the Bank’s assets by an unrelated  entity. |
|--------|----|--------------------------------------------------------------------------------------------------------------------------------------------------------|

| XVII. | AMENDMENT      OR REVOCATION, AND EXCHANGE OFPOLICY |
|-------|-----------------------------------------------------|

| XVIII. | EFFECTIVE      DATE |
|--------|---------------------|

----

| XIX. | SEVERABILITY      AND INTERPRETATION |
|------|--------------------------------------|

| XX. | TERMINATION      OR MODIFICATION OF AGREEMENT BY REASON OF CHANGES IN THE LAW, RULES OR      REGULATIONS |
|-----|----------------------------------------------------------------------------------------------------------|

| XXI. | APPLICABLE      LAW |
|------|---------------------|

|    |   | BANK      OF UPSON                     |
|---------|--------|----------------------------------------|
|    |   | Thomaston,      Georgia                |
|    |   |                                   |
|    |   |                                   |
|    |   |                                   |
|    |   | By:                                    |   |
| Witness |   | (Bank      Officer other than Insured) | Title |
|    |   |                                   |
|    |   |                                   |
|    |   |                                   |
|    |   |                                   |
| Witness |   | Trae      D. Dorough                   |

----

| I.     | PRIMARY      DESIGNATIONS |
|--------|---------------------------|
|   |                      |
|   | A.                        | Person(s)      as a Primary Designation:(Please      indicate the percentage for each beneficiary.) |
|   |                      |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   | 1.                        | Name: |   | Relationship: |   | SS#: |   | % |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   | 2.                        | Name: |   | Relationship: |   | SS#: |   | % |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   | 3.                        | Name: |   | Relationship: |   | SS#: |   | % |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   | 4.                        | Name: |   | Relationship: |   | SS#: |   | % |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   |   |   |   |   |   |   |
|   |                      |   | (Street) |   | (City) |   | (State) | (Zip) |

| II.    | ESTATE AND/OR TRUST AS      PRIMARY DESIGNATIONS |
|--------|--------------------------------------------------|
|   |                                             |   |
|   | A.                                               | Estate as a Primary      Designation:An      Estate can still be listed even if there is no will. |
|   |                                             |  My      Primary Beneficiary is The Estate of |   |  as      set forth in the Last Will and |
|   |                                             |   | (Insert      full name) |   |
|   |                                             | Testament      dated the  |   |        day of  |   |     | ,      200 | and      any codicils thereto. |
|   |                                             |   |
|   | B.                                               | Trust as a Primary      Designation: |
|   |                                             |  Name      of the Trust: |
|   |                                             |  Execution      Date of the Trust: |  Name      of the Trustee: |
|   |                                             |  Beneficiary      of the Trust:(please      indicate the percentage for each beneficiary): |
|   |                                             |  Name(s): |
|   |                                             |  Name(s): |
|   |                                             |  Is this an Irrevocable Life      Insurance Trust?        □      Yes           □ No |
|   |                                             | (If      yes and this designation is for a Joint Beneficiary Designation Agreement,      an Assignment of Rights form must      be completed.) |

----

| III.   | SECONDARY (CONTINGENT)      DESIGNATIONS |
|--------|------------------------------------------|
|   |                                     |   |
|   | A.                                       | Person(s)      as a Secondary (Contingent) Designation:(Please      indicate the percentage for each beneficiary in the event of the Primary’s      Death.) |
|   |                                     |   |   |   |   |   |   |   |
|   | 1.                                       | Name: |   | Relationship: |   | SS#: |   | % |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   | 2.                                       | Name: |   | Relationship: |   | SS#: |   | % |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   | 3.                                       | Name: |   | Relationship: |   | SS#: |   | % |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   | (Street) |   | (City) |   | (State) | (Zip) |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   | 4.                                       | Name: |   | Relationship: |   | SS#: |   | % |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   |   |   |   |   |   |   |
|   |                                     |   | (Street) |   | (City) |   | (State) | (Zip) |

| IV.    | ESTATE AND/OR TRUST AS      SECONDARY (CONTINGENT) DESIGNATIONS |
|--------|-----------------------------------------------------------------|
|   |                                                            |   |
|   | A.                                                              | Estate as a Secondary      (Contingent) Designation: |
|   |                                                            |  My      Primary Beneficiary is The Estate of |   |  as      set forth in the last will and |
|   |                                                            | Testament      dated the |   |        day of  |   |   | ,      200 | and      any codicils thereto. |
|   |                                                            |   |
|   | B.                                                              | Trust as a Secondary      (Contingent) Designation: |
|   |                                                            |  Name      of the Trust: |
|   |                                                            |  Execution      Date of the Trust: |  Name      of the Trustee: |
|   |                                                            |  Beneficiary      of the Trust:(please      indicate the percentage for each beneficiary): |
|   |                                                            |  Name(s): |
|   |                                                            |  Name(s): |
|   |                                                            |  Is this an Irrevocable Life      Insurance Trust?        □      Yes              □ No |
|   |                                                            | (If      yes and this designation is for a Joint Beneficiary Designation Agreement,      an Assignment of Rights form must      be completed.) |

| V.     | SIGN AND      DATE                                                                                       |
|--------|----------------------------------------------------------------------------------------------------------|
|   |                                                                                                     |
|   | This      Beneficiary Designation Form is valid until the participant notifies the      bank in writing. |
|   |                                                                                                     |   |   |
|   |                                                                                                     |   |   |
|   | Trae      D. Dorough                                                                                     |   | Date |

----