Document:

exv4w1

 

Exhibit 4.1

DELPHI CORPORATION

No. 1

[   ]%
JUNIOR SUBORDINATED NOTE

DUE 2033

     DELPHI CORPORATION, a corporation duly organized and existing under the
laws of the State of Delaware (herein called the “Company”, which term includes
any successor corporation under the Indenture hereinafter referred to), for
value received, hereby promises to pay to DELPHI TRUST I, or registered
assigns, the principal sum of [  ] ($[  ]) on October 15, 2033, and to pay
interest thereon from October [  ] or from the most recent Interest
Payment Date to which interest has been paid or duly provided for, quarterly in
arrears on January 15, April 15, July 15 and October 15 of each year, subject
to deferral as set forth herein, commencing January 15, 2004, at the rate of [
 ]% per annum, plus Compounded Interest, if any, until the principal hereof is
paid or made available for payment and (to the extent that the payment of such
interest shall be legally enforceable) at the rate of [  ]% per annum,
compounded quarterly, on any overdue principal and on any overdue
installment of interest. The amount of interest payable on any Interest
Payment Date shall be computed on the basis of a 360-day year of twelve 30-day
months, and for any period shorter than a full month for which interest is
computed, the amount of interest payable will be computed on the basis of the
actual number of days elapsed in such a 30-day month. In the event that any
Interest Payment Date is not a business day, then payment of interest payable
on such date will be made on the next succeeding day which is a business day
(and without any interest or other payment in respect of any such delay),
except that, if such business day is in the next succeeding calendar year, such
payment shall be made on the immediately preceding business day, in each case
with the same force and effect as if made on such date. The interest so
payable, and punctually paid or duly provided for, on any Interest Payment Date
will, as provided in the Indenture, be paid to the person in whose name this
Security (or one or more predecessor Securities) is registered at the close of
business on the Regular Record Date for such interest, which shall be the close
of business on the fifteenth day (whether or not a business day), next
preceding the relevant Interest Payment Date. Any such interest not so
punctually paid or duly provided for (“Defaulted Interest”) will forthwith
cease to be payable to the Holder on such Regular Record Date and may either be
paid to the person in whose name this Security (or one or more predecessor
Securities) is registered at the close of business on a subsequent record date
for the payment of such Defaulted Interest (“Special Record Date”) established
by notice given by mail by or on behalf of the Company to the Holders of Debt
Securities of the series in default not less than fifteen
days preceding such subsequent record date, such record date to be not
less than five days preceding the date of payment of such Defaulted Interest or
such earlier date not inconsistent with the requirements of any securities
exchange on which this Security may be listed, and upon such notice as may be
required by such exchange.

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     Payment of the principal of and any such interest on this Security will be
made at the office or agency of such paying agent or paying agents as the
Company may designate for that purpose in the Borough of Manhattan, the City
and State of New York, in such coin or currency of the United States of America
as at the time of payment is legal tender for payment of public and private
debts; provided, however, that, at the option of the Company, payment of
interest may be made by (i) mailing checks for such interest payable to or upon
the order of such Holders at their last addresses as they appear on the
Security Register for such Debt Securities or (ii) in the case of Holders of
U.S. $10,000,000 or more in aggregate principal amount of such Debt Securities,
by wire transfer of immediately available funds, but only if the Trustee has
received wire transfer instructions in writing not less than 15 days prior to
the applicable Interest Payment Date and provided further that the payment of
principal will only be made upon surrender of this Security to the Trustee.
Notwithstanding the foregoing, so long as the owner and Holder of
record of this
Security is Delphi Trust I (the “Trust”), the payment of the principal of and
interest (including Compounded Interest, if any) on this Security will be made
at such place and to such account of the Trust as may be designated by the
Property Trustee (as hereinafter defined).

     The indebtedness evidenced by this Security is, to the extent provided in
the Indenture, subordinate and subject in right of payment to the prior payment
in full of all Senior Debt, and this Security is issued subject to the
provisions of the Indenture with respect thereto. Each Holder of this
Security, by accepting the same (a) agrees to and shall be bound by such
provisions, (b) authorizes and directs the Trustee on his behalf to take such
action as may be necessary or appropriate to acknowledge or effectuate the
subordination so provided and (c) appoints the Trustee his attorney-in-fact for
any and all such purposes. Each Holder of this Security, by his acceptance of
the same, hereby waives all notice of the acceptance of the subordination
provisions contained herein and in the Indenture by each holder of Senior Debt,
whether now outstanding or hereafter incurred, and waives reliance by each such
Holder upon said provisions.

     Reference is hereby made to the further provisions of this Security set
forth on the reverse hereof, which further provisions shall for all purposes
have the same effect as though fully set forth at this place.

     All terms used in this Security that are defined in the Indenture shall
have the meanings assigned to them in the Indenture.

     Unless the Certificate of Authentication hereon has been executed by the
Trustee by manual signature, this Security shall not be entitled to any benefit
under the Indenture or be valid or obligatory for any purpose.

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     IN WITNESS WHEREOF, the Company has caused this Security to be signed by
any two of its Chairman of the Board, its President, one of its Vice
Chairmen, one of its Vice
Presidents, including its Treasurer, or its Secretary or one of its Assistant
Secretaries, manually or in facsimile, and a facsimile of its corporate seal to
be imprinted hereon.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	DELPHI CORPORATION
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	By:	 	 	 	 	 	 
	 	 	 	 	 	
	 	 
	 	 	 	 	 	 	Name:	 	 	 	 
	 	 	 	 	 	 	Title:	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	By:	 	 	 	 	 	 
	 	 	 	 	 	
	 	 
	 	 	 	 	 	 	Name:	 	 	 	 
	 	 	 	 	 	 	Title:	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	[Corporate Seal]	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	Attest:	 	 	 	 	 	 	 	 	 	 
	 	
	 	 	 	 	 	 	 	 

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TRUSTEE’S CERTIFICATE OF AUTHENTICATION

     This is one of the Securities of the series designated therein referred to
in the within-mentioned Indenture.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	BANK ONE TRUST COMPANY, N.A.,
	 	 	 	 	 	 	as Trustee	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	By:	 	 	 	 	 	 
	 	 	 	 	 	
	 	 	 	 
	 	 	 	 	 	 	Authorized Signatory	 	 	 	 
	Dated:	 	 	 	 	 	 	 	 	 	 
	 	 	
	 	 	 	 	 	 

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FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers unto:

PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER OF ASSIGNEE:

(Print or Type Name and Address including Zip Code of Assignee)

the within Security and all rights, thereunder, hereby irrevocably constituting
and appointing

attorney to transfer said Security on the books of the Company, with full power
of substitution in the premises.

	 	 	 	 	 
	By:	 	 	 	 
	 	 	

	 	 
	Dated:	 	 	 
	 	 	

	 	 

	 	 	 
	NOTE:	 	
The signature to this assignment must correspond with
the name as written upon the face of the within
Security in every particular without alteration or
enlargement or any change whatsoever and must be
guaranteed.

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REVERSE OF SECURITY

DELPHI CORPORATION

[   ]%
JUNIOR SUBORDINATED NOTE

DUE 2033

     This Security is one of a duly authorized issue of securities of the
Company (herein called the “Securities”), issued and to be issued in one or
more series under an Indenture, dated as of October [   ], 2003, (herein
called the “Indenture”), among the Company and Bank One Trust Company, N.A., as
Trustee (herein called the “Trustee”, which term includes any successor trustee
under the Indenture with respect to the series of which this Security is a
part), to which Indenture and all indentures supplemental thereto reference is
hereby made for a statement of the respective rights, limitations of rights,
duties and immunities thereunder of the Company, the Trustee and the Holders of
the Securities and of the terms upon which the Securities are, and are to be,
authenticated and delivered. This Security is one of the Securities of the
series designated on the face hereof, whose issuance on the date hereof is
limited in aggregate principal amount to $[  ].

     The Securities of this series are subject to the defeasance and covenant
defeasance provisions set forth in Article Twelve of the Indenture.

     1. Optional Redemption. Except as provided in the next paragraph, the
Securities may not be redeemed by the Company prior to October 15, 2008. The
Securities of this series are subject to redemption upon not less than 30 nor
more than 60 days’ notice (provided that, so long as any Preferred Securities
(as defined herein) are outstanding, the Company shall give such notice no
later than at such time so as to allow the Property Trustee (as defined herein)
to comply with Section [   ] of the Declaration (as defined herein)) by
mail, at any time on or after October 15, 2008, as a whole or in part, at the
election of the Company (an “Optional Redemption”), at a Redemption Price equal
to 100% of the principal amount of the Security being redeemed, together with
any accrued but unpaid interest, including Compounded Interest, if any, on the
portion of the Security being redeemed, to the Redemption Date.

     The Company may not redeem any Securities in part unless all accrued and
unpaid interest thereon (including Compounded Interest, if any) has been paid
in full on all outstanding Securities. The Company may not, in any case,
redeem the Securities unless all accrued and unpaid interest thereon has been
paid in full on all outstanding Securities through the last Interest Payment
Date before and including the Redemption Date.

     2. Special Redemption. If, at any time, a Tax Event (as defined below) or
an Investment Company Event (as defined below) shall occur and be continuing,
the Company shall have the right at any time, upon not less than 30 nor more
than 60 days’ notice (provided that, so long as any Preferred Securities are
outstanding, the Company shall give such notice no later than at such time so
as to allow the Property Trustee to comply with Section [     ] of the
Declaration),

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(i) in the case of an Investment Company Event, to redeem the Securities
in whole but not in part, and (ii) in the case of a Tax Event, to redeem the
Securities in whole or in part, in each case for cash, within 90 days following
the occurrence of such Tax Event or Investment Company Event, as the case may
be, at a Redemption Price equal to 100% of the principal amount of such
Security plus any accrued and unpaid interest, including Compounded Interest,
if any, to the date fixed for such redemption; provided that, if a Tax Event
shall occur and be continuing, and the Company shall not have (i) redeemed all
of the Securities pursuant to this paragraph or (ii) dissolved Delphi Trust I,
a statutory business trust formed under the laws of the State of Delaware (the
“Trust”), pursuant to Section [   ] of the Amended and Restated
Declaration of Trust of the Trust, dated October [  ], 2003 (the “Declaration
of Trust”), the Company shall pay from time to time to the Trust (and its
permitted successors and assigns under the Declaration of Trust) for so long as
the Trust (or its permitted successor or assignee) is the registered Holder of
the Securities, such additional amounts (the “Additional Sums”) as may be
necessary in order that the amount of distributions (including any Additional
Amounts (as defined in the Declaration of Trust)) then due and payable by the
Trust on the trust preferred securities issued by the Trust (the “Preferred
Securities”) that at such time remain outstanding in accordance with the terms
thereof shall not be reduced as a result of any additional taxes, duties or
other governmental charges to which the Trust has become subject from time to
time as a result of a Tax Event. Whenever in this Security or in the Indenture
there is a reference in any context to the payment of principal of or interest
on the Securities, such mention shall be deemed to include mention of the
payments of the Additional Sums provided for in this paragraph to the extent
that, in such context, Additional Sums are, were or would be payable in respect
thereof pursuant to the provisions of this paragraph and express mention of the
payment of Additional Sums (if applicable) in any provision hereof shall not be
construed as excluding Additional Sums in those provisions hereof where such
express mention is not made; provided that the extension of an interest payment
period pursuant to this Security shall not extend the payment of any Additional
Sums that may be due and payable during such interest payment period.

     “Tax Event” means the receipt by the property trustee of the Trust (the
“Property Trustee”), on behalf of the Trust, of an Opinion of Counsel, rendered
by a law firm having a recognized national tax and securities law practice
(which opinion shall not have been rescinded by such law firm), to the effect
that, as a result of any amendment to, or change (including any announced
prospective change) in, the laws (or any regulations thereunder) of the United
States or any political subdivision or taxing authority thereof or therein
affecting taxation, or as a result of any official administrative pronouncement
or judicial decision interpreting or applying such laws or regulations, which
amendment or change is effective or such pronouncement or decision is announced
on or after the date of issuance of any Preferred Securities, there is more
than an insubstantial risk in each case that (i) the Trust is, or will be
within 90 days of the date of such Opinion of Counsel, subject to United States
federal income tax with respect to income received or accrued on the
Securities, (ii) interest payable by the Company on the Securities is not, or
within 90 days of the date of such Opinion of Counsel will not be, deductible
by the Company, in whole or in part, for United States federal income tax
purposes or (iii) the Trust is, or will be within 90 days of the date of such
Opinion of Counsel, subject to more than a de minimis amount of other taxes,
duties or other governmental charges.

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     “Investment Company Event” means the receipt by the Property Trustee, on
behalf of the Trust, of an Opinion of Counsel, rendered by a law firm having a
recognized national securities law practice (which opinion shall not have been
rescinded by such law firm), to the effect that, as a result of the occurrence
of a change in law or regulation or a change in interpretation or application
of law or regulation by any legislative body, court, government agency or
regulatory authority on or after the date of original issuance of the Preferred
Securities, there is more than an insubstantial risk that the Trust is or will
be considered an “investment company” that is required to be registered under
the Investment Company Act of 1940, as amended.

     3. Redemption Procedures. If the Securities are only partially redeemed
by the Company pursuant to an Optional Redemption or as a result of a Tax Event
as described above, the Securities will be redeemed pro rata or by lot or by
any other method as the Trustee shall deem fair and appropriate.

     In the event of redemption of this Security in part only, a new Security
or Securities of this series for the unredeemed portion hereof will be issued
in the name of the Holder hereof upon the cancellation hereof.

     4. Event of Default. If an Event of Default with respect to Securities of
this series shall occur and be continuing, the principal of the Securities of
this series may be declared due and payable in the manner and with the effect
provided in the Indenture.

     5. Interest Deferral. So long as no Event of Default has occurred and is
continuing, the Company shall have the right to defer the payment of
interest (including any Additional Sums) on
such
Securities at any time during the term of such Securities, from time
to time,
for a period not exceeding 20 consecutive quarterly interest periods
(the “Extended Interest Payment Period”), provided,
that no
Extended Interest Payment Period may extend beyond the Stated
Maturity of the Securities.
On the Interest Payment Date occurring at the end of the Extended
Interest Payment Period, the
Company shall pay all interest then accrued and unpaid (together with interest
thereon at the rate of [        ]% per annum compounded quarterly to the
extent permitted by applicable law (“Compounded Interest”)).
During such Extended Interest Payment
Period, the Company shall not declare or pay any dividends, distributions or
interest on, or redeem, purchase, acquire or make a liquidation,
principal or premium payment with respect to, any of its Common Stock,
preferred stock or any other securities similar to the Preferred Securities or
debt securities of the Company ranking equally in right of payment with or
junior to the Securities, and shall not make any guarantee payments with respect thereto;
provided, however, that, during any such Extended Interest Payment Period, the
Company may (i) make any dividend, redemption, liquidation, interest, principal
or guarantee payment in the form of Common Stock, (ii) purchase, redeem or
otherwise acquire Common Stock in connection with any employee benefit
plans or any other contractual
obligation of the Company, other than a contractual obligation ranking equally
with or junior to the Securities, (iii) make payments under the Guarantee (as
defined in the Declaration of Trust) with respect to the Preferred Securities,
(iv) make payments or distributions in connection with a reclassification of
the Company’s capital stock; provided such reclassification does not result in
the issuance of securities senior to the Securities, and (v) make any payments
or distributions in connection with an exchange or conversion of any securities
of the Company for any class or series of the Company’s capital stock that is
junior to the Securities

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(including the purchase of fractional interests thereof). Prior to the
termination of any such Extended Interest Payment Period, the Company may
further extend such Extended Interest Payment Period, provided that such
Extended Interest Payment Period, together with all such further extensions
thereof, shall not exceed 20 consecutive quarterly interest periods or extend
beyond the Stated Maturity of the Securities. During
an Extended Interest Payment Period, the Company may pay all or any portion of
the interest accrued on the Securities on any Interest Payment Date to Holders
of record on the Regular Record Date for such Interest Payment Date. At the termination of any such Extended Interest Payment Period
and upon the payment of all accrued and unpaid interest then due, together with
Compounded Interest, the Company may select a new Extended Interest Payment
Period, subject to the foregoing requirements. No interest on this Security
shall be due and payable during an Extended Interest Payment Period, except at
the end thereof. At the end of the Extended Interest Payment Period, the
Company shall pay all interest accrued and unpaid on the Securities including
any Compounded Interest which shall be payable to the Holders of the Securities
in whose names the Securities are registered in the Security Register on the
Regular Record Date for the first Interest Payment Date occurring on or after
the end of the Extended Interest Payment Period.

     So long as the Property Trustee is the sole owner and Holder of record of
the Securities at the time the Company selects an Extended Interest Payment
Period, the Company shall give both the Property Trustee and the Trustee
written notice of its selection of such Extended Interest Payment Period ten
business days prior to the earlier of (i) the next succeeding date on which
distributions on the Preferred Securities are payable or (ii) the date the
Trust is required to give notice of the record date or the date such
distributions are payable to the New York Stock Exchange or other applicable
self-regulatory organization or to holders of the Preferred Securities but in
any event not less than one business day prior to such record date. The
Company shall cause the Trust to give notice of the Company’s selection of such
Extended Interest Payment Period to the holders of Preferred Securities.

     If, as a result of an Early Termination Event (as defined in the
Declaration of Trust), Securities have been distributed to holders of Preferred
Securities, at the time the Company selects an Extended Interest Payment
Period, the Company shall give the Holders of Securities and the Trustee
written notice of its selection of such Extended Interest Payment Period at
least ten business days prior to the earlier of (i) the next succeeding
Interest Payment Date or (ii) the date the Company is required to give notice
of the record or payment date of such interest payment to the New York Stock
Exchange (if the Securities are then listed thereon) or other applicable
self-regulatory organization or to Holders of the Securities.

     6. Amendments and Waivers. The Indenture permits, with certain exceptions
as therein provided, the Company, when authorized by a Board
Resolution, and the Trustee, with the consent of the
Holders of not less than a majority in the aggregate principal amount of the
Debt Securities of all series affected at the time outstanding (voting as one
class), to execute supplemental indentures for the purpose of adding any
provisions to or changing in any manner or eliminating any of the provisions of
the Indenture or of any supplemental indenture or of modifying in any manner
the rights of the Holders of the Debt Securities; provided, however, that no
such supplemental indenture shall (i) change the fixed maturity of any Debt
Securities, or reduce the principal amount thereof (or

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premium, if any), or reduce the rate or extend the time of payment of any
interest or Additional Amounts thereon or reduce the amount due and payable
upon acceleration of the maturity thereof or the amount provable in bankruptcy,
or make the principal of (premium, if any) or interest, if any, or Additional
Amounts, if any, on any Debt Security payable in any coin or currency other than
that provided in such Debt Security, (ii) impair the right to institute suit for the
enforcement of any such payment on or after the Stated Maturity (or, in the
case of redemption, on or after the Redemption Date), or (iii) reduce the
aforesaid percentage of Debt Securities, the Holders of which are required to
consent to any such supplemental indenture, without the consent of the Holders
of each Debt Security then outstanding. The Indenture also contains provisions
permitting the Holders of a majority in aggregate principal amount of the
Debt Securities of all series at the time outstanding affected thereby, on behalf of
the Holders of the Debt Securities of such series, to waive compliance by the
Company with certain provisions of the Indenture and certain past defaults
under the Indenture and their consequences. Any such consent or waiver by the
Holder of this Security (unless revoked as provided in the Indenture) shall be
conclusive and binding upon such Holder and upon all future Holders of this
Security and of any Security issued upon the registration of transfer hereof or
in exchange or in lieu hereof, whether or not notation of such consent or
waiver is made upon this Security. In addition, the Indenture permits the
Company and the Trustee, under certain circumstances set forth in the
Indenture, when authorized by a Board Resolution (as defined in the Indenture)
to enter into an indenture or supplemental indentures without the consent of
the Holders of Debt Securities.

     Subject
to Article Twelve of the Indenture, no reference herein to the
Indenture (other than such Section) and no provision of this Security or of the
Indenture shall alter or impair the obligation of the Company, which is
absolute and unconditional, to pay the amount of principal of (and premium, if
any, on) and interest on this Security herein provided, and at the times, place
and rate, and in the coin or currency, herein prescribed.

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     7. Agreed Tax Treatment. The Company and, by acceptance of a Security or
a beneficial interest therein, the Holder of, and any person that acquires a
beneficial interest in, such Security, agree that for United States federal,
state and local tax purposes it is intended that such Security constitute
indebtedness.

     8. Listing of Securities upon Distribution to Preferred Security Holders.
In connection with the distribution of the Securities to the holders of the
Preferred Securities upon an Early Termination Event, the Company will use its
best efforts to list such Securities on the New York Stock Exchange or on such
other exchange as the Preferred Securities are then listed and traded.

     9. Transfer of Securities. As provided in the Indenture and subject to
certain limitations therein set forth, the transfer of this Security is
registrable in the Security Register, upon surrender of this Security for
registration of transfer at the office or agency of the company in the Borough
of Manhattan, the City and State of New York, duly endorsed by, or accompanied
by a written instrument of transfer in form satisfactory to the Company and the
Security Registrar duly executed by, the Holder hereof or his attorney duly
authorized in writing, and thereupon one or more new Securities of this series,
of authorized denominations and for the same aggregate principal amount, will
be issued to the designated transferee or transferees.

     Except as provided below, the Securities of this series are issuable only
in registered form without coupons in denominations of U.S. $25 and, to the
extent practicable, any integral multiple thereof. As provided in the
Indenture and subject to certain limitations therein set forth, Securities of
this series are exchangeable for a like aggregate principal amount of
Securities of this series of different authorized denominations as requested by
the Holder surrendering the same. In connection with the distribution of
Securities to holders of the Preferred Securities in connection with an Early
Termination Event:

     (i) the Securities in certificated form may be presented to the
Trustee by the Property Trustee in exchange for one or more Global
Securities in an aggregate principal amount equal to the aggregate
principal amount of all outstanding Securities, to be registered in the
name of the Depository, or its nominee, and delivered by the Trustee to
the Depository, or its custodian, for crediting to the accounts of its
participants pursuant to the procedures of the Depository. The Company
upon any such presentation shall execute a Global Security in such
aggregate principal amount and deliver the same to the Trustee for
authentication and delivery in accordance with the Indenture; and

     (ii) if any Preferred Securities are held in non book-entry
certificated form, the Security in certificated form may be presented to
the Trustee by the Property Trustee and any Preferred Security
certificate which represents Preferred Securities other than Preferred
Securities held by the Depository Trust Company (or any permitted
successor thereto) (the “Depository”) or its nominee (“Non Book-Entry
Preferred Securities”) will be deemed to represent beneficial interests
in Securities presented to the Trustee by the Property Trustee having an
aggregate principal amount equal to the aggregate liquidation amount of
the Non Book-Entry Preferred Securities until such Preferred Security
certificates are presented to the Security Registrar for transfer or
reissuance at which time such Non Book-Entry Preferred Security
certificates will be canceled and a Security, registered in the name of
the Holder of the Preferred Security.

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certificate or the transferee of the Holder of such Preferred
Security certificate, as the case may be, with an aggregate principal
amount equal to the aggregate liquidation amount of the Preferred
Security certificate canceled, will be executed by the Company and
delivered to the Trustee for authentication and delivery in accordance
with the Indenture. On issue of such Securities, Securities with an
equivalent aggregate principal amount that were presented by the Property
Trustee to the Trustee will be deemed to have been canceled.

     Prior to due presentment of this Security for registration of transfer,
the Company, the Trustee and any agent of the Company, or the Trustee may treat
the person in whose name this Security is registered as the owner hereof for
all purposes, whether or not this Security be overdue, and neither the Company,
the Trustee nor any such agent shall be affected by notice to the contrary.

     THE LAW OF THE STATE OF NEW YORK SHALL GOVERN THE INDENTURE AND THE
SECURITIES.

     All terms used in this Security which are defined in the Indenture and not
otherwise defined herein shall have the meanings assigned to them in the
Indenture.

7<PAGE>
                                  EXHIBIT 10(v)

                            THE CROGHAN COLONIAL BANK
                      SUPPLEMENTAL DEATH BENEFIT AGREEMENT

       THIS AGREEMENT is adopted this 3rd day of September, 2003, by and between
The Croghan Colonial Bank, an Ohio state-chartered commercial bank located in
Fremont, Ohio (the "Company"), and [NAME OF EXECUTIVE]1 (the "Executive").

                                     PURPOSE

       To encourage the Executive to remain an employee of the Company, the
Company is willing to provide a supplemental death benefit to the Executive.

                                    AGREEMENT

       The Company and the Executive agree as follows:

                                    ARTICLE 1
                                   DEFINITIONS

       Whenever used in this Agreement, the following words and phrases shall
have the meanings specified:

         1.1 "Change of Control" means the transfer of shares of the Company's
voting common stock such that one entity or one person acquires (or is deemed to
acquire when applying Section 318 of the Code) more than 50 percent of the
Company's outstanding voting common stock followed within twelve (12) months by
the Executive's Termination of Employment for reasons other than death,
Disability or retirement.

         1.2 "Code" means the Internal Revenue Code of 1986, as amended.

         1.3 "Disability" means the Executive's suffering a sickness, accident
 or injury which has been determined by the carrier of any individual or group
 disability insurance policy covering the Executive, or by the Social Security
 Administration, to be a disability rendering the Executive totally and
 permanently disabled. The Executive must submit proof to the Company of the
 carrier's or Social Security Administration's determination upon the request of
 the Company.

         1.4 "Early Termination" means the Termination of Employment before
Normal Retirement Age for reasons other than death, Disability, Termination for
Cause or following a Change of Control.

         1.5 "Early Termination Date" means the month, day and year in which
Early Termination occurs.

         1.6 "Effective Date" means September 3, 2003.

         1.7 "Normal Retirement Date" means the later of the Normal Retirement
Age or Termination of Employment.

         1.8 "Termination for Cause" shall be defined as set forth in Article 5.

         1.9 "Termination of Employment" means that the Executive ceases to be
employed by the Company for any reason, voluntary or involuntary.

                                       15
<PAGE>

                                    ARTICLE 2
                                 DEATH BENEFITS

       2.1 Amount of Benefit. Subject to Article 5, the supplemental death
benefit is $25,000.00 (Twenty-Five Thousand Dollars).

       2.2 Death. Subject to Article 5, when the Executive dies the Company
shall pay to the Executive's beneficiary the benefit described in this Section
2.1.

       2.3 Payment of Benefit. The Company shall pay the benefit to the
Executive's beneficiary in a lump sum payment the month following the
Executive's death.

                                    ARTICLE 3
                                  BENEFICIARIES

       3.1 Beneficiary Designations. The Executive shall designate a beneficiary
by filing the written designation form provided by the Company. The Executive
may revoke or modify the designation at any time by filing a new designation.
However, designations will only be effective if signed by the Executive and
received and acknowledged by the Company during the Executive's lifetime.

       3.2 Facility of Payment. If a benefit is payable to a minor, to a person
declared incompetent, or to a person incapable of handling the disposition of
his or her property, the Company may pay such benefit to the guardian, legal
representative or person having the care or custody of such minor, incompetent
person or incapable person. The Company may require proof of incompetence,
minority or guardianship as it may deem appropriate prior to distribution of the
benefit. Such distribution shall completely discharge the Company from all
liability with respect to such benefit.

                                    ARTICLE 4
                               GENERAL LIMITATIONS

       4.1 Termination for Cause. Notwithstanding any provision of this
Agreement to the contrary, the Company shall not pay any benefit under this
Agreement if the Company terminates the Executive's employment for:

             (a) Gross negligence or gross neglect of duties;

             (b) Commission of a felony or of a misdemeanor involving moral
       turpitude; or

             (c) Fraud, disloyalty, dishonesty or willful violation of any law
       or significant Company policy committed in connection with the
       Executive's employment and resulting in an adverse effect on the Company.

Any such termination for cause will be at the sole determination of the Company.

        4.2 Suicide or Misstatement. The Company shall not pay any benefit under
this Agreement if the Executive commits suicide within three years after the
date of this Agreement. In addition, the Company shall not pay any benefit under
this Agreement if the Executive has made any material misstatement of fact on an
employment application or resume provided to the Company, or on any application
for any benefits provided by the Company to the Executive.

                                       16
<PAGE>

                                    ARTICLE 5
                          CLAIMS AND REVIEW PROCEDURES

       5.1 Claims Procedure. Any individual ("claimant") who has not received
benefits under the Agreement that he or she believes should be paid shall make a
claim for such benefits as follows:

                5.1.1 Initiation - Written Claim. The claimant initiates a claim
         by submitting to the Company a written claim for the benefits. This
         written claim must be filed within six months after death has occurred.

                5.1.2 Timing of Company Response. The Company shall respond to
         such claimant within 30 days after receiving the claim. If the Company
         determines that special circumstances require additional time for
         processing the claim, the Company can extend the response period for
         such period of time as the Company reasonably determines by notifying
         the claimant in writing, prior to the end of the initial 30-day period,
         that an additional period is required. The notice of extension must set
         forth the special circumstances and the date by which the Company
         expects to render its decision.

                5.1.3 Notice of Decision. If the Company denies the entire
         claim, the Company shall notify the claimant in writing of such denial.
         The Company shall write the notification in a manner calculated to be
         understood by the claimant.

       5.2 Review Procedure. If the Company denies part or all of the claim, the
claimant shall have the opportunity for a review by the Company of the denial,
as follows:

               5.2.1 Initiation - Written Request. To initiate the review, the
         claimant, within 60 days after receiving the Company's notice of
         denial, must file with the Company a written request for review. Should
         a request not be filed within 60 days the claimant shall be deemed to
         have waived all of its rights to initiate a review to contest the
         decision of the Company.

               5.2.2 Additional Submissions - Information Access. The claimant
         may file with the appeal any written comments, documents, records and
         other information relating to the claim. The Company shall also provide
         the claimant, upon request and free of charge, reasonable access to,
         and copies of, all documents, records and other information relevant
         (as defined in applicable ERISA regulations) to the claimant's claim
         for benefits.

               5.2.3 Considerations on Review. In considering the review, the
         Company shall take into account all materials and information the
         claimant submits relating to the claim, without regard to whether such
         information was submitted or considered in the initial benefit
         determination.

               5.2.4 Timing of Company Response. The Company shall respond in
         writing to such claimant within 60 days after receiving the request for
         review. If the Company determines that special circumstances require
         additional time for processing the claim, the Company can extend the
         response period for a period of time as the Company reasonably
         determines by notifying the claimant in writing, prior to the end of
         the initial 60-day period, that an additional period is required. The
         notice of extension must set forth the special circumstances and the
         date by which the Company expects to render its decision.

               5.2.5 Notice of Decision. The Company shall notify the claimant
         in writing of its decision on review. The Company shall write the
         notification in a manner calculated to be understood by the claimant.

              5.2.6 Nothing contained in Article 5 shall be construed as
         providing a right to a Review for Termination for Cause.

                                       17
<PAGE>

                                    ARTICLE 6
                           AMENDMENTS AND TERMINATION

        This Agreement may be amended or terminated only by a written agreement
signed by the Company and the Executive.

                                   ARTICLE 7
                                 MISCELLANEOUS

       7.1 Binding Effect. This Agreement shall bind the Executive and the
Company, and their beneficiaries, survivors, executors, successors,
administrators and transferees.

       7.2 No Guarantee of Employment. This Agreement is not an employment
policy or contract. It does not give the Executive the right to remain an
employee of the Company, nor does it interfere with the Company's right to
discharge the Executive. It also does not require the Executive to remain an
employee nor interfere with the Executive's right to terminate employment at any
time.

       7.3 Non-Transferability. Benefits under this Agreement cannot be sold,
transferred, assigned, pledged, attached or encumbered in any manner.

       7.4 Reorganization. The Company shall not merge or consolidate into or
with another company, or reorganize, or sell substantially all of its assets to
another company, firm, or person unless such succeeding or continuing company,
firm, or person agrees to assume and discharge the obligations of the Company
under this Agreement. Upon the occurrence of such event, the term "Company" as
used in this Agreement shall be deemed to refer to the successor or survivor
company.

       7.5 Tax Withholding. The Company shall withhold any taxes that are
required to be withheld from the benefits provided under this Agreement.

       7.6 Applicable Law. The Agreement and all rights hereunder shall be
governed by the laws of the State of Ohio, except to the extent preempted by the
laws of the United States of America.

       7.7 Unfunded Arrangement. The Executive and beneficiary are general
unsecured creditors of the Company for the payment of benefits under this
Agreement. The benefits represent the mere promise by the Company to pay such
benefits. The rights to benefits are not subject in any manner to anticipation,
alienation, sale, transfer, assignment, pledge, encumbrance, attachment, or
garnishment by creditors. Any insurance on the Executive's life is a general
asset of the Company to which the Executive and beneficiary have no preferred or
secured claim.

       7.8 Entire Agreement. This Agreement constitutes the entire agreement
between the Company and the Executive as to the subject matter hereof. No rights
are granted to the Executive by virtue of this Agreement other than those
specifically set forth herein.

       7.9 Administration. The Company shall have powers which are necessary to
administer this Agreement, including but not limited to:

              (a) Establishing and revising the method of accounting for the
       Agreement;

              (b) Maintaining a record of benefit payments;

              (c) Establishing rules and prescribing any forms necessary or
       desirable to administer the Agreement; and

                                       18
<PAGE>

       IN WITNESS WHEREOF, the Executive and the Company have signed this
Agreement.

EXECUTIVE: (1)                             COMPANY:  THE CROGHAN COLONIAL BANK

(1)

_____________________________________      BY__________________________________

                                           ITS_________________________________

(1) On September 3, 2003 the following Executive Officers of the Corporation
and/or the Bank entered into Supplemental Death Benefit Agreements with the
Bank, all of which Agreements have substantially identical terms: Jodi A.
Albright, Thomas J. Elder Jr., and Steven C. Futrell.

                                       19

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