EX-99 4 0004.txt EXHIBIT 99.1 Exhibit 99.1 AUTHORIZATION FORM DIVIDEND REINVESTMENT AND STOCK PURCHASE PLAN ------------------------------------------------------------------------------- [INDEPENDENT COMMUNITY To participate in the Independent BANKSHARES, INC. LOGO] Community Bankshares, Inc. Dividend Reinvestment and Stock Purchase Plan, please complete and sign the reverse side of this authorization card, and return it in the envelope provided to: Registrar and Transfer Company Attn: Dividend Reinvestment Department 10 Commerce Drive Cranford, NJ 07106 This will authorize Independent Community Bankshares, Inc. to pay to Registrar and Transfer Company, as your agent, all or a portion of the regular dividends you receive on common shares of Independent Community Bankshares, Inc., to be used together with any voluntary cash contributions you may make to purchase additional common shares of Independent Community Bankshares, Inc. (Please see Reverse Side) NOTE: This Is Not A Proxy Completion and return of this Authorization Form authorizes your enrollment in the Independent Community Bankshares, Inc. Dividend Reinvestment and Stock Purchase Plan. Do not return this form unless you wish to participate in the Plan. _ |_| Full Common Stock Dividend Reinvestment and Optional Cash Purchases - If you check this option, you authorize the purchase of additional shares of Common Stock with the cash dividends on all shares of Common Stock held by you, as well as on the shares of Common Stock credited to your Plan account. In addition, you authorize the purchase of additional shares of Common Stock with voluntary cash payments of not less than $100 per payment, up to a maximum of $5,000 per calendar quarter, made by you at any time. _ |_| Partial Dividend Reinvestment and Optional Cash Purchases - If you check this option, you authorize the purchase of additional shares of Common Stock with (i) the cash dividends on __________% of the shares (25%, 50%, 75%) of Common Stock held by you and (ii) the cash dividends on all of the shares of Common Stock credited to your Plan account. In addition, you authorize the purchase of additional shares of Common Stock with voluntary cash payments of not less than $100 per payment, up to a maximum of $5,000 per calendar quarter, made by you at any time. _ |_| Optional Cash Purchases - If you check this option, you authorize only the purchase of additional shares of Common Stock with voluntary cash payments of not less than $100 per payment, up to a maximum of $5,000 per calendar quarter, made by you at any time. Note: Checks submitted for Optional Cash Purchases of stock must be received not less than 2 business days prior to the date that the purchases will be made. (See Prospectus for details) I understand that the purchases will be made under the terms and conditions of the Dividend Reinvestment and Stock Purchase Plan as described in the Prospectus that accompanied this Authorization Form and that I may revoke this authorization at any time by notifying Registrar and Transfer Company, in writing, of my desire to terminate my participation. Please return this Authorization Form in the envelope provided to: Registrar and Transfer Company, 10 Commerce Drive, Cranford, New Jersey 07016 Sign here exactly as name(s) appear on stock certificate(s). If shares are held jointly, all holders must sign. Shareholder X_________________Date_____ Shareholder X__________________Date_____