Vt. Stat. Ann. tit. 24, § 1782

It is hereby certified that upon the written request of the holder of the within bond, the coupons attached thereto, being ________ in number, of __________________ each have been this day cut off and destroyed and that the within bond is hereby converted into a registered bond with the interest thereon payable ____________ annually, and that such interest, as well as the principal, is payable to the registered holder thereof, his or her legal representatives, successors, or assigns at the time and place expressed on the face of such bond. The within bond when registered is transferable only upon the books of the treasurer of ______________ upon presentation to the treasurer with a written assignment duly acknowledged or proved. Date ____________ 20 ______. Treasurer of _______________________________________________ _________________________________________________________ Date of registration. __________________________________________________________________ Name and address of registered holder. Signature of treasurer who acts as transfer agent.