Document:

Unassociated Document

    

    

    

    EXHIBIT
      4.3

    

    
 

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    
      	
               

              NUMBER

            	
               

              ADCARE
                HEALTH SYSTEMS, INC.

               

              LOGO

            	
               

              UNITS

            

    

     

    SEE
      REVERSE FOR CERTAIN

    DEFINITIONS
      CUSIP ____________

     

    ADCARE
      HEALTH SYSTEMS, INC.

    INCORPORATED
      UNDER THE LAWS OF THE STATE OF OHIO

     

    This
      Certifies that [•]

     

    is
      the
      owner of [•]

     

    FULLY
      PAID AND NON-ASSESSABLE UNITS OF

    ADCARE
      HEALTH SYSTEMS, INC.

     

    transferable
      on the books of the Corporation by the registered holder hereof in person or
      by
      duly authorized attorney, upon surrender of this Certificate properly endorsed.
      Each Unit (a "Unit") consists of two (2) shares of common stock, [•] par value
      per share (the "Common Stock"), of AdCare Health Systems, Inc., an Ohio
      corporation (the "Corporation"), and two (2) warrants to purchase one share
      of
      Common Stock (the "Warrant"). Each Warrant entitles the holder to purchase
      one
      (1) share of Common Stock for $[•] per share (subject to adjustment). The
      Warrants will become exercisable beginning [•], 2006 and will expire unless
      exercised before [5:00 p.m., Eastern Standard Time, on [•], 2011, or earlier
      upon redemption.]

     

    This
      Certificate is not valid until countersigned and registered by the Transfer
      Agent.

     

    IN
      WITNESS WHEREOF, the said Corporation has caused this Certificate to be signed
      by its duly authorized officers and sealed with the facsimile seal of the
      Corporation.

     

    Dated:
      _________, 2006

    

     

    
      	 	 	 
	 	
               

              ADCARE
                HEALTH SYSTEMS, INC.

               

              CORPORATE
                SEAL OHIO

            	 
	
               

              President

            	 	
               

              Secretary

            

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Countersigned
      and Registered:

     

    [INSERT
      NAME OF WARRANT AGENT].

     

    By:

    ___________________________

    Authorized
      Officer

     

     

    
      
        
        

      

      
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    The
      Common Stock and Warrants comprising the Units represented by this Unit
      Certificate are not transferable separately prior to separation. The Warrants
      comprising part of the Units are issued under and pursuant to a certain Warrant
      Agreement, dated as of [______], 2006, between the Corporation and [•], as
      Warrant Agent, and are subject to the terms and provisions contained therein
      and
      on the face of the certificates issued pursuant thereto, all of which terms
      and
      provisions the holder of this Unit Certificate consents to by acceptance hereof.
      The Warrant Agreement provides for adjustment in the number of shares of Common
      Stock to be delivered upon the exercise of the Warrant and to the exercise
      price
      of such Warrant upon the occurrence of certain events set forth in the Warrant
      Agreement. Copies of the Warrant Agreement are on file at the office of the
      Warrant Agent at [•] and are available to any Warrant holder on written request
      and without cost.

     

    The
      registered holder of this Unit Certificate hereby is entitled, at any time
      after
      the separation of the Units, to exchange the Units represented by this Unit
      Certificate for Common Stock Certificate(s) representing two shares of Common
      Stock for each Unit represented by this Unit Certificate and two Warrant
      Certificates representing two Warrants to each purchase one share of Common
      Stock for each Unit represented by this Unit Certificate, upon surrender of
      this
      Unit Certificate to the Transfer Agent together with any documentation required
      by such agent.

     

    REFERENCE
      IS MADE TO THE WARRANT AGREEMENT REFERRED TO ABOVE, AND THE PROVISIONS OF SUCH
      WARRANT AGREEMENT SHALL FOR ALL PURPOSES HAVE THE SAME EFFECT AS THOUGH FULLY
      SET FORTH ON THE FACE OF THIS UNIT CERTIFICATE. COPIES OF THE WARRANT AGREEMENT
      MAY BE OBTAINED UPON WRITTEN REQUEST FROM THE WARRANT AGENT [NAME OF WARRANT
      AGENT].

     

    The
      Corporation will furnish to any shareholder, upon request and without charge,
      a
      full statement of the voting and other powers, designations, preferences,
      limitations, restrictions and relative, participating, optional, or other
      special rights of each class of stock or series thereof which the Corporation
      is
      authorized to issue and the qualifications, limitations or restrictions of
      such
      powers, preferences and/or rights. Any such request is to be addressed to the
      Corporation.

     

    The
      following abbreviations, when used in the inscription on the face of this
      certificate, shall be construed as though they were written out in full
      according to applicable laws or regulations:

    

    
      	 
	
              UNIF
                GIFT MIN ACT -- under Uniform Gift to Minors Act __________
                (STATE)

              (cust)
                -- Custodian

              (min)
                -- minor

              TEN
                COM -- as
                tenants in common

              TEN
                ENT -- as
                tenants by the entireties and not as tenants in common

              JT
                TEN -- as
                joint tenants with right of
                survivorship

            

    

     

    Additional
      abbreviations may also be used though not in the above list.

     

    For
      Value
      Received, _______________ hereby sell, assign and transfer unto

     

    
      
        
        

      

      
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          3
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    PLEASE
      INSERT SOCIAL SECURITY OR OTHER

    IDENTIFYING
      NUMBER OF ASSIGNEE

     

    _______________________________________________

     

    _______________________________________________

     

    
      
        

      

    

    (PLEASE
      PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF
      ASSIGNEE)

     

    
      
        

      

       

    

    
      
        

      

       

    

    
      
        

      

       

    

    Units
      represented by the within certificate, and do hereby irrevocably constitute
      and
      appoint

     

    
      
        

      

    

    Attorney
      to transfer the said Units on the books of the within named Corporation with
      full power of substitution in the premises.

     

    Dated
      _____________________________

     

    
      
        

      

    

     

    
      	
            	NOTICE:	
              THE
                SIGNATURE TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME AS WRITTEN
                UPON
                THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION
                OR
                ENLARGEMENT OR ANY CHANGE WHATEVER.

            

    

     

    Signature(s)
      Guaranteed

     

    By
      ________________________________________________________

     

    THE
      SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS,
      STOCK-BROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP
      IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE
      17Ad-15.

     

    KEEP
      THIS
      CERTIFICATE IN A SAFE PLACE. IF IT IS LOST, STOLEN, OR DESTROYED, THE
      CORPORATION MAY REQUIRE A BOND OF INDEMNITY AS A CONDITION TO THE ISSUANCE
      OF A
      REPLACEMENT CERTIFICATE.

     

     

    
      
        
        

      

      
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          4
          -Unassociated Document

     

     

    
 

    EXHIBIT
      4.4

     

     

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    (SEE
      REVERSE LEGEND)

     

    (THIS
      WARRANT WILL BE VOID IF NOT EXERCISED PRIOR

     

    TO
      5:00
      P.M. EASTERN STANDARD TIME,         ,
      2011)

     

    
      	
               

              Number

            	
               

              ADCARE
                HEALTH SYSTEMS, INC.

            	
               

              Warrants

            

    

     

    WARRANT

     

    CUSIP
      ____________

     

    THIS
      CERTIFIES THAT, for value received, [•]

     

    is
      the
      registered holder of a Warrant expiring [•], 2011 (the "Warrant") to purchase
      one fully paid and non-assessable share of Common Stock, [•] par value
      ("Shares"), of AdCare Health Systems, Inc., an Ohio corporation (the "Company")
      for each one Warrant evidenced by this Warrant Certificate. The Warrant entitles
      the holder thereof to purchase from the Company, commencing on the date the
      Warrant is separated from the Unit of which it is a part, such number of Shares
      of the Company at the price of $[•] per share, upon surrender of this Warrant
      Certificate and payment of the Warrant Price at the office or agency of the
      Warrant Agent, [name of warrant agent] (such payment to be made by check made
      payable to the Warrant Agent), but only subject to the conditions set forth
      herein and in the Warrant Agreement between the Company and [name of warrant
      agent]. The Warrant Agreement provides that upon the occurrence of certain
      events the Warrant Price and the number of Warrant Shares purchasable hereunder,
      set forth on the face hereof, may, subject to certain conditions, be adjusted.
      The term Warrant Price as used in this Warrant Certificate refers to the price
      per Share at which Shares may be purchased at the time the Warrant is
      exercised.

     

    No
      fraction of a Share will be issued upon any exercise of a Warrant. If the holder
      of a Warrant would be entitled to receive a fraction of a Share upon any
      exercise of a Warrant, the Company shall, upon such exercise, round up to the
      nearest whole number the number of Shares to be issued to such
      holder.

     

    Upon
      any
      exercise of the Warrant for less than the total number of full Shares provided
      for herein, there shall be issued to the registered holder hereof or his
      assignee a new Warrant Certificate covering the number of Shares for which
      the
      Warrant has not been exercised.

     

    Warrant
      Certificates, when surrendered at the office or agency of the Warrant Agent
      by
      the registered holder hereof in person or by attorney duly authorized in
      writing, may be exchanged in the manner and subject to the limitations provided
      in the Warrant Agreement, but without payment of any service charge, for another
      Warrant Certificate or Warrant Certificates of like tenor and evidencing in
      the
      aggregate a like number of Warrants.

     

    
      
        
        

      

      
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          2
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    Upon
      due
      presentment for registration of transfer of the Warrant Certificate at the
      office or agency of the Warrant Agent, a new Warrant Certificate or Warrant
      Certificates of like tenor and evidencing in the aggregate a like number of
      Warrants shall be issued to the transferee in exchange for this Warrant
      Certificate, subject to the limitations provided in the Warrant Agreement,
      without charge except for any applicable tax or other governmental
      charge.

     

    The
      Company and the Warrant Agent may deem and treat the registered holder as the
      absolute owner of this Warrant Certificate (notwithstanding any notation of
      ownership or other writing hereon made by anyone), for the purpose of any
      exercise hereof, of any distribution to the registered holder, and for all
      other
      purposes, and neither the Company nor the Warrant Agent shall be affected by
      any
      notice to the contrary.

     

    This
      Warrant does not entitle the registered holder to any of the rights of a
      stockholder of the Company until exercised.

     

    Countersigned:

    

    

    [insert
      name of warrant agent]

    

    
      	 	
               

              as
                Warrant Agent,

            	
               

              ADCARE
                HEALTH 

              SYSTEMS,
                INC.

              CORPORATE
                SEAL

            	
               

              By:

            
	
               

              By:

               

            	 	 	 

    

     

    OHIO

    X

    
      	
               

              Authorized
                Officer:

            	
               

              Secretary:

            	
               

              President:

            
	
               

              ________________________

            	
               

              _______________________

            	
               

              __________________________

            

    

    
 

    
      
        
        

      

      
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    SUBSCRIPTION
      FORM

     

    To
      Be
      Executed by the Registered Holder in Order to Exercise Warrants

     

    The
      undersigned Registered Holder irrevocably elects to exercise [•] Warrants
      represented by this Warrant Certificate, and to purchase the shares of Common
      Stock issuable upon the exercise of such Warrants, and requests that
      Certificates for such shares shall be issued in the name of

     

    
      
        

      

    

    (PLEASE
      TYPE OR PRINT NAME AND ADDRESS)

     

    
      
        

      

    

     

    
      
        

      

    

     

    
      
        

      

    

    (SOCIAL
      SECURITY OR TAX IDENTIFICATION NUMBER)

     

    and
      be
      delivered to

     

    
      
        

      

    

    (PLEASE
      PRINT OR TYPE NAME AND ADDRESS)

     

    
      
        

      

    

     

    and,
      if
      such number of Warrants shall not be all the Warrants evidenced by this Warrant
      Certificate, that a new Warrant Certificate for the balance of such Warrants
      be
      registered in the name of, and delivered to, the Registered Holder at the
      address stated below:

     

    

    
      	
               

              Dated:
                ___________________

            	 
	 	
              (SIGNATURE)

               

            
	 	
              (ADDRESS)

               

            
	 	
              (TAX
                IDENTIFICATION NUMBER)

            

    

     

     

    
      
        
        

      

      
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    ASSIGNMENT

     

    To
      Be
      Executed by the Registered Holder in Order to Assign Warrants

     

    For
      Value
      Received, _____________________________________ hereby sell, assign, and
      transfer unto

     

    
      
        

      

    

    (PLEASE
      TYPE OR PRINT NAME AND ADDRESS)

     

    
      
        

      

    

     

    
      
        

      

    

     

    
      
        

      
(SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER)

     

    and
      be
      delivered to

     

    
      
        

      

    

    (PLEASE
      TYPE OR PRINT NAME AND ADDRESS)

     

    ____________________________________of
      the Warrants represented by this Warrant Certificate, and hereby irrevocably
      constitute and appoint

     

    ___________________________________________________________
      Attorney to transfer this Warrant Certificate on the books of the Company,
      with
      full power of substitution in the premises.

     

    
      	
               

              Dated:
                ___________________

            	 
	 	
              (SIGNATURE)

               

            

    

     

    THE
      SIGNATURE TO THE ASSIGNMENT OF THE SUBSCRIPTION FORM MUST CORRESPOND TO THE
      NAME
      WRITTEN UPON THE FACE OF THIS WARRANT CERTIFICATE IN EVERY PARTICULAR, WITHOUT
      ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATSOEVER, AND MUST BE GUARANTEED
      BY A
      COMMERCIAL BANK OR TRUST COMPANY OR A MEMBER FIRM OF THE AMERICAN STOCK
      EXCHANGE, NEW YORK STOCK EXCHANGE, PACIFIC STOCK EXCHANGE/ARCAEX OR CHICAGO
      STOCK EXCHANGE.

     

    
       

      
        
          
          

        

        
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            5
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