NOTICE TO PARENT OR GUARDIAN: The Children’s Online Privacy Protection Act (COPPA) was enacted to regulate the online collection of personal information from children under the age of 13. In compliance with COPPA, parents or guardians of children under the age of 13 must consent to collections, uses and disclosures of the personal information of their children collected online. Farmers State Bank’s website is not directed towards children, and Farmers State Bank (Bank) does not knowingly collect personal information from children online; however, children who have accounts at the Bank (for example, the Books and Bucks checking account) may utilize the bank’s online services with prior written parental or guardian consent. The bank’s COPPA statement is incorporated in the website’s Site Privacy Policy, BANKWITHFARMERS.COM/PRIVACY-POLICY.

Federal banking regulations require the Bank to collect certain personal information about all customers, such as name, address, date of birth and e-mail, in order to offer a financial product or service. The Bank may have collected your name and online contact information from your child in order to obtain your consent. Your consent is required for the collection, use and disclosure of your child’s personal information. This personal information is generally in the form of account nicknames, telephone numbers, physical address, e-mail address, username, password or external IP information of the device used to access the bank’s online services. The Bank will not grant your child access to any of the bank’s online services unless you provide us with written consent.

PARENT OR GUARDIAN CONSENT:

Return by mail to: Farmers State Bank 307 Main St PO Box 330 Westmoreland, KS 66549 or drop off at the nearest branch location.

Child’s Name:

Child’s E-mail Address:

Child’s Date of Birth (Month/Date/Year):

ACKNOWLEDGMENT:

By signing and returning this form to Farmers State Bank, you certify that you consent to the collection, use and disclosure of your child’s personal information.

Parent or Guardian Name:

Relationship to Child:

Parent or Guardian E-mail Address:

Parent or Guardian Mailing Address:

Parent or Guardian Signature: Date:

Revocation: You may revoke your consent at any time to refuse further collection and use of your child’s information. Revocation of consent may limit or prohibit access to some or all features of the bank’s online services. If you desire to revoke this consent, mail your revocation to: Farmers State Bank 307 Main St PO Box 330 Westmoreland, KS 66549 or drop it off at the nearest branch location.

BANKWITHFARMERS.COM/KEEPING-YOUR-CHILD-SAFE-ONLINE

Westmoreland . Manhattan . Onaga

COPPA PARENTAL OR GUARDIAN CONSENT FORM