Exhibit 99.1
AUTHORIZATION FORM
DIVIDEND REINVESTMENT AND STOCK PURCHASE PLAN
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[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)
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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.
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|_| 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_____
