Retirement of Capital Stock Acquisition of Treasury Stoc

RETIREMENT OF CAPITAL STOCK/ACQUISITION OF TREASURY STOCK
APPLICATION
Application No.:
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contained on the type of capital/dividend application/notice that you completed. We have
provided all questions for your review to ensure that you have an opportunity to see those
questions that you answered and the questions that you did not previously see or answer.
Your attention should be focused on those questions with answers, with the other
questions provided for your information.

National Bank Identifying Information
Charter No.:
Name of Bank:
Street address:
City:
County:
State:
Zip:
Supervisory
District:
Filing Fee: $
Stock Repurchase Details
Number of shares to be repurchased:
Common Stock:
Preferred Stock:
The repurchasing of the stock is to:

Description of how the stock buy back will be accomplished and the method used
to establish a price:

[For Treasury Stock]Description of the business purpose for retention of the
shares:

The effects of the change on the equity capital accounts and capital ratios are
detailed in the attached Pro Forma Balance Sheet and Projected Regulatory Capital
Schedule (click on the link to open the balance sheet and projected capital
schedule, save the blank document, complete the balance sheet and capital
schedule, and upload the completed document):

The bank:
_ Is currently subject to a capital plan filed with the Comptroller of the Currency.
- Capital Plan:
_ Is not currently subject to a capital plan filed with the Comptroller of the Currency.
The proposed change conforms to the capital plan by:

The bank:
_ has obtained
_ will obtain
shareholder approval of the (retirement of capital stock/acquisition of treasury
stock) on date:
The bank:
_ has prepared
_ will prepare
proxy materials under 12 CFR11 and
_ has filed
_ will file
such proxy materials with the Securities and Corporate Practices Division.
Contact Person Requests for additional information or other communications about this proposal
should be directed to:
Name:
Title:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Additional Attachments

Desired Action Date
I/We desire OCC action on this application no later than .
Certification
The resulting capital structure will comply with all statutory minimum capital
requirements, including 12 USC 51(capital requirements), 12 USC 371d(investment
in bank premises), and 12 CFR 6(prompt corrective action).
I hereby certify that the bank's board of directors has authorized the filing of this
application, and that to the best of my knowledge, it contains no
misrepresentations or omissions of material facts. In addition, I agree to notify the
OCC if the facts described in the filing materially change prior to receiving a
decision.
I acknowledge that any misrepresentation or omission of a material fact constitutes
fraud in the inducement and may subject me to legal sanctions provided by 18 USC
1001 and 1007.
I acknowledge that approval of this application is in the discretion of the
Comptroller of the Currency. Actions or communications, whether oral, written, or
electronic, by an agency or its employees in connection with this filing, including
approval of the application if granted, do not constitute a contract, either express or
implied, or any other obligation binding upon the agency, other federal banking
agencies, the United States, any other agency or entity of the United States, or any
officer or employee of the United States. Such actions or communications will not
affect the ability of the agency to exercise its supervisory, regulatory, or
examination powers under applicable law and regulations. I further acknowledge
that the foregoing may not be waived or modified by any employee or agent of a
federal banking agency or of the United States.

I agree _I do not agree
(If you do not indicate that you agree with the terms of the certification you cannot certify.)
Signature
Signature of Authorized Officer:
Typed Name:
Title:
Date:
Name of Bank:
BankNet Security verified that was a valid signer for as of .