Capital Stock Payment Certificate

Capital Stock Payment Certificate
The undersigned officers and directors of (name of bank, city, state)
the provisions of the United States Code, as amended, certify that:

now organizing under

1.

Each shareholder has individually paid, in cash, 100 percent of his or her subscription for
stock in the proposed bank.

2.

The capital accounts paid in, in cash, no part of which is represented by promissory notes
or other evidences of debt in favor of the organizing bank, are as follows:
Capital Stock
Surplus
Total capital funds paid in

$
$
$

3.

All of the provisions of the United States Code, as amended, which must be followed before
receiving authority to commence the business of banking, have been complied with.

4.

The names and places of residence of all bank directors and the number of shares of bank
stock individually owned in good faith by each of them are as follows:

(The typed or printed names, but not the signatures, of all directors must be listed.)
Number of
Total
Place of Residence
Shares of
Number
Name of Director
(town or city, state)
Stock Owned*
of Shares

* Include shares beneficially owned.
(A majority of the directors, exclusive of the president or cashier, must sign in the following
spaces provided for directors’ signatures.)

________________________________
(President or Cashier)

___________________________________
Director
___________________________________
Director
___________________________________
Director
___________________________________
Director
___________________________________
Director