IDOB
LIST OF SHAREHOLDERS
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|PLEASE NOTE THESE INSTRUCTIONS: |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. |
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 | |$ | |$ |
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|SHAREHOLDER NAME |ADDRESS |# SHARES |SHAREHOLDER NAME |ADDRESS |# SHARES |
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, President, and , Cashier, of the (Bank), , 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, personally appeared and , to me known to be the 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) | | |
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