EX-99.5 29 a2156305zex-99_5.txt EXHIBIT 99.5 EXHIBIT 99.5 PATRIOT NATIONAL BANCORP, INC. NOMINEE HOLDER OVERSUBSCRIPTION CERTIFICATION The undersigned, a bank, broker or other nominee holder of Rights ("Rights") to purchase shares of Common Stock, $2.00 par value per share ("Common Stock"), of Patriot National Bancorp, Inc. (the "Company") pursuant to the Rights offering (the "Offering") described and provided for in the Company's Prospectus dated _______, 2005 (the "Prospectus"), hereby certifies to the Company and to Registrar and Transfer Company, as Subscription Agent for such Offering, that for each numbered line filled in below the undersigned has exercised, on behalf of the beneficial owner thereof (which may be the undersigned), the number of Rights specified on such line pursuant to the Basic Subscription Right (as defined in the Prospectus) and such beneficial owner wishes to subscribe for the purchase of additional shares of Common Stock pursuant to the Oversubscription Privilege (as defined in the Prospectus), in the amount set forth in the second column of such line:
NUMBER OF RIGHTS EXERCISED NUMBER OF SHARES SUBSCRIBED FOR PURSUANT TO BASIC SUBSCRIPTION RIGHT PURSUANT TO OVERSUBSCRIPTION PRIVILEGE -------------------------------------- -------------------------------------- 1. ___________________________________ _________________________________________________ 2. ___________________________________ _________________________________________________ 3. ___________________________________ _________________________________________________ 4. ___________________________________ _________________________________________________ 5. ___________________________________ _________________________________________________ 6. ___________________________________ _________________________________________________ 7. ___________________________________ _________________________________________________ 8. ___________________________________ _________________________________________________ 9. ___________________________________ _________________________________________________ 10. __________________________________ _________________________________________________ Provide the following information, if applicable: _______________________________ _____________________________________ Name of Nominee Holder Depository Trust Company ("DTC") Participant Number By ----------------------------- ------------------------------------------------- Name: DTC Basic Subscription Title: Confirmation number(s) Dated:________________________, 2005