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Bank's Name Transit / Routing Number First State Bank 1010-0100-5 Originating Bank's Address 650 Kansas Avenue Kansas City, Kansas 66105-1348 P O Box 5188 Kansas city, Kansas 66119-0188 Originating Bank's Telephone Numbers Tel: 913-371-1242 Originating Bank's Tax ID # Fax: 913-371-7516 48 - 0221590 On behalf of myself or the organization named, I request First State Bank to initiate the following wire transfer and I authorize the Bank to charge the account shown for the wire amo.

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