EX-99 5 dex99.txt AUTHORIZATION FORM EXHIBIT 99 Authorization Form [FRONT VIEW] VENTAS, INC. Distribution Reinvestment and Stock Purchase Plan Enrollment and Authorization
INVESTMENT OPTIONS: Check [X] all that apply: (Please indicate your selection by [X]) [_] I am not currently a registered stockholder on the books [_] I. Full Distribution Reinvestment - Reinvest the of Ventas, Inc. Please open a new account for me. distributions on shares of Ventas, Inc. common stock registered in my name as well as on all shares held in my [_] My check for my initial purchase in the amount of $_______ plan account. Also purchase shares with any optional is also enclosed. (Amount must be a minimum of $250 and a cash payments I may send to you. maximum of $5,000 per month. Checks must be made payable to National City Bank.) [_] II. Partial Distribution Reinvestment - Reinvest distributions earned on only ______ shares registered in Please provide information below to open a new plan account. my name. Distributions earned on shares held in my plan account, including shares purchased with any optional Please type or print cash payments I may send to you, are to be reinvested. Account Name(s): ____________________________________________________ [_] III. Optional Cash Payments Only - Invest my optional cash payments and distributions earned on shares held in my Address: ____________________________________________________ plan account without reinvesting distributions on any shares held outside of my plan account. ____________________________________________________ Distribution reinvestments are limited to $25,000 per quarter ____________________________________________________ and optional cash payments are limited to $5,000 per calendar month, unless Ventas, Inc. waives the limitations for a Social Security or Taxpayer I.D. Number: _____________________ participant. To obtain a request for waiver, contact National City Bank at 800-622-6757. Daytime phone: _______________________________________________ Unless you are already a registered stockholder of Ventas, Inc., Please complete both sides of this form you must open a new account to become a registered participant in the plan. You are not considered a registered stockholder if you own shares in "street" name or participate in the plan through your stock broker.
[REVERSE VIEW] VENTAS, INC. Distribution Reinvestment and Stock Purchase Plan Enrollment and Authorization I wish to participate in Ventas, Inc.'s Distribution Reinvestment and Stock Purchase Plan. I hereby authorize Ventas, Inc. to pay to National City distributions payable to me on shares of Ventas, Inc. common stock registered in my name or held in my plan account and appoint National City as my agent to purchase shares of Ventas, Inc. as designated on the reverse side. I understand that I may terminate my participation at any time. To establish your plan account, you are required to complete, sign and return the enclosed Request for Taxpayer Identification Number and Certification Form W-9 with this enrollment form. Signature: _____________________________________________________ (All owners must sign exactly as account is entitled) Signature:______________________________________________________ Date: __________________________________________________________ MAIL THIS FORM TO: National City Bank Reinvestment Services P.O. Box 94946 Cleveland, Ohio 44101-4946 Please complete both sides of this form