Irrevocable Stock or Bond Power Form
FOR VALUE RECEIVED,_____________________________________
Hereby sell, assign, and transfer unto:
The Columbus Foundation
1234 East Broad Street
Columbus, Ohio 43205
866/263-6001 614/251-4000
EIN: 31-6044264
IF STOCK, _________________ shares of the _____________________________ stock of
COMPLETE _______________________________________________________________
THIS represented by Certificate No. ________________________________ inclusive,
PORTION standing in the name of the undersigned on the books of said company.
IF BONDS, _________________ bonds of _______________________________________
COMPLETE _______________________________________________________________
THIS in the principal amount of $_______________________, No. _______________
PORTION inclusive, standing in the name of the undersigned on the books of said company.
The undersigned does (do) hereby irrevocably constitute and appoint _____________________
--------------------------------------------------------- attorney to transfer the said stock or bond, as the case
may be, on the books of said company with full power of substitution in the premises.
Dated _________________________
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In the presence of
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__________________________________ | _____________________________________ |
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| _____________________________________ |
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Read carefully: The signature(s) of the person(s) executing this assignment must be guaranteed by a bank or trust company or by a member of the national stock exchange, and must correspond with the name as written upon the face of the certificate in every particular without alteration or enlargement or any change whatever.