Sale of Capital Stock for Other Than Cash Application

SALE OF CAPITAL STOCK FOR OTHER THAN CASH APPLICATION
Application No.:
For your convenience, the application/notice that you are reviewing includes all questions
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: $
Capital Increase Details
We wish to change our corporate structure by issuing:
Number of
Par Value($)
Shares
Common Stock:
Preferred Stock:
For:(Description of Property)

Value($):
Property Valuation Method:

If applicable, upload a copy of the appraisal of the property:

[For preferred stock] The terms of the preferred stock are as follows: [Describe the
terms(e.g., voting rights, convertible, cumulative, redeemable, preference rights,
dividend rate, issue price). Alternatively, a copy of the preferred stock agreement
can be provided.]

A copy of the amendment, or proposed amendment, to the Articles of Association
authorizing the preferred stock can be uploaded:

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):

Shareholders:
_ Do need to approve an increase in authorized shares.
_ Do not need to approve an increase in authorized shares.

Current Authorized Shares
Common Stock:
Preferred Stock:

Outstanding Shares

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 plan by:
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 .