LIST OF SHAREHOLDERS
PREPARE THIS LIST AS OF THE DATE OF THE ANNUAL MEETING. ARRANGE LIST IN ALPHABETICAL ORDER, LISTING PREFERRED SHARES AND COMMON SHARES IN SEPARATE GROUPS.
PLEASE NOTE THESE INSTRUCTIONS:
A list of the shareholders of the
(Bank) of
, Iowa, their
addresses, and the number of shares subscribed and paid for in full by each shareholder of the Bank as of the close of business , .
Number of Shares
Par Value Per Share
Total Par Value of Stock Outstanding
Preferred Shares Common Shares
...... ......
$ $
...... ......
$ $
SHAREHOLDER NAME
ADDRESS
# SHARES
SHAREHOLDER NAME
ADDRESS
# SHARES
SHAREHOLDER NAME
ADDRESS
# SHARES
SHAREHOLDER NAME
ADDRESS
# SHARES
, President, and (Bank),
, Cashier, of the
, Iowa, hereby certify that the above-named shareholders are
the present shareholders of this bank, that the number of shares set opposite their names have been paid for in cash, and that no part thereof has been borrowed for the purpose of being exhibited as an asset of the bank.
President
Cashier
STATE OF IOWA SS. COUNTY OF On this day of , A.D. , before me, a Notary Public in and for said county and state, and , to me known to be the personally appeared person(s) named in and who executed the foregoing instrument, and acknowledged that (they) (he) (she) executed the same as (their) (his) (her) voluntary act and deed.
My Commission Expires
Notary Public
(Notary Seal)