Exhibit 4.1


 


FARMERS AND MERCHANTS BANCSHARES,
INC.


DIVIDEND REINVESTMENT PLAN


 


AUTHORIZATION FORM FOR DIVIDEND
REINVESTMENT






This form is to be used
by an eligible stockholder of Farmers and Merchants Bancshares, Inc. (the “Company”) who desires to (i) enroll in
the Company’s Dividend Reinvestment Plan (the “Plan”), (ii) change his or her level of participation in the
Plan, and (iii) terminate his or her participation in the Plan. The Plan is not available to stockholders of record who reside
in Arizona, California or Ohio, or to any other stockholder who resides in any jurisdiction to whom it is unlawful for the Company
to make offers or sales under the Plan in such jurisdiction. Complete and sign below and return it in the enclosed envelope.


 


This form will authorize
the Company to forward to the administrator of the Plan all or a portion of the dividends paid on your shares of the Company’s
common stock to be invested in additional shares of common stock. All investments are made subject to the terms and conditions
of the Plan as set forth in the prospectus in respect of the Plan. This form is also to be used by a participant who desires to
terminate his or her participation and thereby receive all cash dividends.


 


This authorization is given
by you with the understanding that you may terminate it at any time by so notifying the administrator of the Plan.


 


If you choose partial dividend
reinvestment or you terminate your participation in the Plan and would like to have your dividends deposited automatically into
your checking or savings account, complete the section below for Direct Deposit.


 





	 	Please read carefully.
	 	This is not a proxy.
	 	Return this form only
	 	if you wish to
	 	participate in the Plan.







 





Please enroll me in the Plan


 


		 ̈	Full
                                         Dividend Reinvestment. Please apply the dividends on all shares of common stock that
                                         I currently own as well as all future shares that I acquire.



 


		 ̈	Partial
                                         Dividend Reinvestment. Please apply the dividends on _________ shares of common stock
                                         that I currently own (the “Plan Shares”) and remit to me the dividends on
                                         all other shares that I own.



 


			I understand that the dividends on my Plan Shares, as well as all
                                         future shares that I acquire under the Plan, will be reinvested under the Plan.



 


		 ̈	Terminate
                                         Participation – Receive All Cash (no dividend reinvestment)



 


By signing below, I represent that I have received a copy of the
prospectus, dated [*], relating to the Plan, as amended and supplemented to date.


 


	Date:	 	 	 
	 	 	 
	Signature(s):	 	Print Name(s):
	 	 	 
	 	 	 
	 	 	 
	 	 	 


 


All joint owners must sign exactly as names appear on
the stock certificates.


 




     


     


    

  


		 ̈	Direct
                                         Deposit (check this box only if you checked “Partial Dividend Reinvestment”
                                         or “Terminate Participation – Receive All Cash” above). I hereby
                                         authorize American Stock Transfer & Trust Company, LLC (the “Administrator”)
                                         and Farmers and Merchants Bancshares, Inc. (the “Company”) to initiate cash
                                         dividend deposits into my account indicated below and the financial institution below
                                         to deposit the same to such account. This authority is to remain in full force and effect
                                         until the Administrator or the Company has received written notification from me of its
                                         termination in such time and manner as to afford them a reasonable opportunity to act
                                         on it. If this option is not selected, your dividend check will be automatically mailed
                                         to your address.



 


			(You must complete this section and return the form along with a
                                         personal voided check to enroll for Direct Deposit of your dividends. Your financial
                                         institution can provide you with the following required information.)



 


Type of Account: ̈
Checking ̈ Savings


 


	Financial Institution RT/ABA Number:	 
	 	 
	Address of Financial Institution:	 
	 	 
	Checking/Savings Account Number:	 


 


	Signatures (All Holders Must Sign)	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	(Print Name)	(Date)	 	(Print Name)	(Date)


 


	Mail completed form to:	American Stock Transfer & Trust Company, LLC
	 	Wall Street Station
	 	P.O. Box 922
	 	New York, NY 10269-0560