DCB FINANCIAL CORP DIVIDEND REINVESTMENT AND STOCK PURCHASE PLAN
Shareholder Authorization Form (See mailing instructions below)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name(s) exactly as set forth on your stock certificate
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Additional space for name(s) if necessary
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Street Address
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City State Zip Code
_ _ _ - _ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _
Social Security Number (To be Employer Identification Number (To
completed if the shareholder is an be completed if the shareholder is
individual. If shares are held jointly, not an individual.)
the Social Security Number should be
that of the first person listed on the
stock certificate.
__ I am a U.S. Citizen or Resident Alien
__ I am a Nonresident Alien
1. Dividend Reinvestment (Check only one option - fill in amount where appropriate)
__ a. Full Cash Dividend Reinvestment. I wish to reinvest under the Plan
cash dividends on all shares registered in my name.
__ b. Partial Cash Dividend Reinvestment. I wish to have cash dividends
reinvested on ________ shares personally held by me in certificate
form and on all Plan shares held in my name. I wish to have the balance
of my cask dividends mailed to me.
2. Optional Cash Investments (minimum $100 and maximum $2,000 per calendar
quarter) (Check the option and fill in amount if you want to invest.)
_ Cash Payment. Please buy shares with the enclosed check or money order
for $________________ payable to Delaware County Bank and Trust Company.
To the extent I have so designated, I hereby elect to participate in the Plan
and authorize Delaware County Bank and Trust Company, as my agent, to apply
cash dividends and any optional cash investments received by it on my behalf
to the purchase of shares of DCB Financial Corp. Common Stock. I understand
that all dividends received or shares credited to my Plan account will be
automatically reinvested in DCB Financial Corp. Common Stock.
____________________________________________________ *
Signature
____________________________________________________ *
Signature
Date _______________________________________________
(Please sign above exactly as name appears on reverse
side. If shares are held jointly, each shareholder must
aign.)
* Under penalties of perjury, I certify (1) that the number shown above on this
Form is my correct Taxpayer Identification Number and (2) that I am not subject
to backup withholding because: (a) I am exempt from backup withholding, or (b) I
have not been notified by the Internal Revenue Service (the "IRS") that I am subject
to backup withholding as a result of failure to report all interest or dividends,
or (c) the IRS has notified that I am no longer subject to backup withholding.
Print this form, complete and sign it, and then mail it to:
Delaware County Bank and Trust
Attn: Shareholder Relations
P.O. Box 1001
Lewis Center, Ohio 43035
|
