EX-99.6 11 v340970_ex99-6.htm EXHIBIT 99.6

 

Exhibit 99.6

 

CONSUMERS BANCORP, INC.

NOMINEE HOLDER CERTIFICATION

 

The undersigned, a broker, custodian bank, trustee, depository or other nominee holder of subscription rights (the “Subscription Rights”) to purchase shares of common stock, without par value (“Common Stock”) of Consumers Bancorp, Inc. (the “Company”) pursuant to the rights offering (the “Rights Offering”) described and provided for in the Company’s registration statement on Form S-1/A, and final prospectus dated          , 2013 (the “Prospectus”), hereby certifies to the Company and Registrar and Transfer Company, as subscription agent of the Rights Offering, that (1) the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the number of Subscription Rights specified below pursuant to the basic subscription privilege and on behalf of beneficial owners of Subscription Rights who have subscribed for the purchase of additional shares of Common Stock pursuant to the over-subscription privilege, listing separately below each such exercised basic subscription privilege and the corresponding over-subscription privilege (without identifying any such beneficial owners), and (2) each such beneficial owner’s basic subscription privilege has been exercised in full if shares are subscribed for pursuant to the over-subscription privilege:

 

Number of Shares of

Common Stock Owned on the

Record Date

 

Rights Exercised

Pursuant to Basic

Subscription Privilege

 

Number of Shares

Subscribed for Pursuant

to the Over-Subscription

Privilege

1.        
2.        
3.        
4.        
5.        
6.        
7.        
8.        
9.        
10.        
         

Provide the following information, if applicable:

 

Depository Trust Company (“DTC”) Participant Number  
   
Participant Name  
   
DTC Basic Subscription Confirmation Number(s)  

 

Name of Broker, Custodian Bank, Trustee, Depository or Other Nominee   

 

By:  
Name:   
Title: