0001209191-19-019604.txt : 20190315
0001209191-19-019604.hdr.sgml : 20190315
20190315103605
ACCESSION NUMBER: 0001209191-19-019604
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20190314
FILED AS OF DATE: 20190315
DATE AS OF CHANGE: 20190315
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Waltz-Jaskolski Donna M.
CENTRAL INDEX KEY: 0001718888
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36192
FILM NUMBER: 19683516
MAIL ADDRESS:
STREET 1: 100 TIA TRAIL
CITY: LOWELL
STATE: MI
ZIP: 49331
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: CIVISTA BANCSHARES, INC.
CENTRAL INDEX KEY: 0000944745
STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022]
IRS NUMBER: 341558688
STATE OF INCORPORATION: OH
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 100 EAST WATER ST
STREET 2: P O BOX 5016
CITY: SANDUSKY
STATE: OH
ZIP: 44870
BUSINESS PHONE: 4196254121
MAIL ADDRESS:
STREET 1: 100 EAST WATER ST
STREET 2: P O BOX 5016
CITY: SANDUSKY
STATE: OH
ZIP: 44870
FORMER COMPANY:
FORMER CONFORMED NAME: FIRST CITIZENS BANC CORP /OH
DATE OF NAME CHANGE: 19950502
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2019-03-14
0
0000944745
CIVISTA BANCSHARES, INC.
CIVB
0001718888
Waltz-Jaskolski Donna M.
1730 SANDPIPER COURT
HURON
OH
44839
0
1
0
0
Senior Vice President
Common
2019-03-14
4
A
0
564
0.00
A
680
D
Restricted shares granted from Civista Bancshares Inc's 2017 Incentive Plan are subject to time-based vesting.
/s/Amy L Grant, by power of attorney
2019-03-15
EX-24.4_842630
2
poa.txt
POA DOCUMENT
LIMITED POWER OF ATTORNEY FOR
SECTION 16 REPORTING OBLIGATIONS
Know all by these presents, that the undersigned's hereby makes, constitutes
and appoints James O. Miller, Chairman of the Board and Chief Executive Officer;
Dennis G. Shaffer, President; Richard J. Dutton, Executive Vice President or Amy
L. Grant, Vice President as the undersigned's true and lawful attorney-in-fact,
with full power and authority as hereinafter described on behalf of and in the
name, place and stead of the undersigned to:
(1) prepare, execute, acknowledge, deliver and file Forms 3, 4, and 5 (including
any amendments thereto) with respect to the securities of Civista Bancshares,
Inc., an Ohio corporation (the "Company"), with the United States Securities and
Exchange Commission, any national securities exchanges and the Company, as
considered necessary or advisable under Section 16(a) of the Securities Exchange
Act of 1934 and the rules and regulations promulgated thereunder, as amended
from time to time (the "Exchange Act");
(2) seek or obtain, as the undersigned's representative and on the undersigned's
behalf, information on transactions in the Company's securities from any third
party, including brokers, employee benefit plan administrators and trustees, and
the undersigned hereby authorizes any such person to release any such
information to the undersigned and approves and ratifies any such release of
information; and
(3) perform any and all other acts which in the discretion of such
attorney-in-fact are necessary or desirable for and on behalf of the undersigned
in connection with the foregoing.
The undersigned acknowledges that:
(1) this Power of Attorney authorizes, but does not require, such
attorney-in-fact to act in their discretion on information provided to such
attorney-in-fact without independent verification of such information;
(2) any documents prepared and/or executed by such attorney-in-fact on behalf of
the undersigned pursuant to this Power of Attorney will be in such form and will
contain such information and disclosure as such attorney-in-fact, in his or her
discretion, deems necessary or desirable;
(3) neither the Company nor such attorney-in-fact assumes (i) any liability for
the undersigned's responsibility to comply with the requirement of the Exchange
Act, (ii) any liability of the undersigned for any failure to comply with such
requirements, or (iii) any obligation or liability of the undersigned for profit
disgorgement under Section 16(b) of the Exchange Act; and
(4) this Power of Attorney does not relieve the undersigned from responsibility
for compliance with the undersigned's obligations under the Exchange Act,
including without limitation the reporting requirements under Section 16 of the
Exchange Act.
The undersigned hereby gives and grants the foregoing attorney-in-fact full
power and authority to do and perform all and every act and thing whatsoever
requisite, necessary or appropriate to be done in and about the foregoing
matters as fully to all intents and purposes as the undersigned might or could
do if present, hereby ratifying all that such attorney-in-fact of, for and on
behalf of the undersigned, shall lawfully do or cause to be done by virtue of
this Limited Power of Attorney.
This Power of Attorney shall remain in full force and effect until revoked by
the undersigned in a signed writing delivered to such attorney-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 25th day of September, 2017.
Donna M. Waltz-Jaskolski
Signature
Donna M. Waltz-Jaskolski
Print Name
STATE OF OHIO
COUNTY OF ERIE
On this 25th day of September, 2017, Donna M. Waltz-Jaskolski personally
appeared before me, and acknowledged that s/he executed the foregoing instrument
for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
Lisa K. Rhenish
Notary Public
February 13, 2020
My Commission Expires: