EXHIBIT 99.1
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Stock Offering Expires
Time
____________, 1998
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Stock Center
First Kansas Financial Corporation
(Holding Company for First Kansas FSA)
STOCK ORDER FORM
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Number of Shares
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Number of Shares Purchase Price Total Payment Due
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X $10.00
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The minimum number of shares that may be subscribed for is __ and the maximum
number is ______ shares per individual or per account. The limit for any person
together with their associates or persons acting in concert in the Conversion is
______ shares. Management has the discretion to increase or decrease the
purchase limit within regulations. Orders of $25,000 or more must be paid by
First Kansas FSA account withdrawals, certified funds, cashier's check or money
order.
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Method of Payment
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|_| Enclosed is a check or money order made payable to Do not mail cash. Please take cash payment in
First Kansas FSA for $________ person to any First Kansas FSA office.
|_| I authorize First Kansas FSA to withdraw the indicated amounts from the following First Kansas FSA
accounts, and understand that the amounts will not otherwise be available for withdrawal.
Account Number Amount
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$ To withdraw from an account with check
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$ the Stock Center for IRA transactions.)
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$ There will be no penalty for early withdrawals
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$
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Purchaser Information
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|_| Check here if you are a director, officer or employee of First Kansas FSA or
a member of their immediate families.
|_| Check here if you were a depositor on ____, 199_, ____, 199_, or ____, 199_.
If you check this box, please enter all your account information for each
of these dates on reverse side: (If you need additional space, please
attach a separate sheet.)
|_| I am not acting in concert with any other persons purchasing stock in
the Conversion nor are any of my associates purchasing stock.
|_| I am acting in concert with the following purchasers and/or the following
purchasers are my associates: ____________, ____________, ____________.
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Stock Registration
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Please review the guidelines on the back of this form. Print the name(s) in
which you want the stock registered and the mailing address for the
registration. Names must appear exactly as on your account at First Kansas FSA
if you are subscribing as an Eligible Account Holder, Supplemental Account
Holder or Other Member.
SUBSCRIPTION RIGHTS ARE NOT TRANSFERABLE.
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Form of ownership: Please check one.
o Individual o Tenants in common o Uniform Transfers to Minors Act
o Joint Tenants o Corporation or partnership o Uniform Gifts to Minors Act
o Other _________________ o Fiduciary ________________________
please specify adoption date
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Name Social Security or Tax I.D. No.
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Name Evening Telephone
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Street Address Daytime Telephone
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City State Zip County of Residence
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NASD Affiliation
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Please read the NASD Affiliation section on the reverse NASD member or person associated with an NASD member has a beneficial
side of this form: Check if applicable and initial where interest. In accordance with the conditions for an exception from the
indicated with *. interpretation, I agree (I) not to sell, transfer or hypothecate this
stock for a period of 90 days following issuance and (ii) to report
o Check here if you are a member of the NASD or a this subscription in writing to the applicable NASD member I am
person associated with an NASD member or a partner associated with within one day of payment of the stock.
with a securities brokerage firm or a member of *_______________________________________(Initial)
the immediate family of any such person to whose
support such person contributes directly or
indirectly or if you have an account in which an
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Acknowledgements
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To purchase stock in the Subscription Offering, this fully completed Stock Order
Form must be actually received by First Kansas FSA no later than_________,
Central Time on _______, 1998 unless extended, otherwise this Stock Order Form
and all subscription rights will be void. Completed Stock Order Forms, together
with the required payment or withdrawal authorization and signed Certification,
may be delivered to First Kansas FSA or may be mailed to the ___________
indicated on the enclosed business reply envelope. All rights exercisable
hereunder are not transferable and shares purchased upon exercise of such rights
must be purchased for the account of the person exercising such rights. The
undersigned certifies that this stock order is for my account only and there is
no agreement or understanding regarding the transfer of my subscription rights
or any further sales or transfer of these shares.
It us understood that this Stock Order Form will be accepted in accordance with,
and subject to, the terms and conditions of the Plan of Conversion of First
Kansas FSA described in the accompanying __________, receipt of which is hereby
acknowledged at least 48 hours prior to delivery of this Stock Order Form to
First Kansas FSA. If the minimum shares cannot be sold, all orders will be
canceled and funds received as payment will be returned promptly.
The undersigned agrees that after receipt by First Kansas Financial Corporation,
this Stock Order Form may not be modified, withdrawn or canceled (unless the
Conversion is not completed by________, 1998) and if First Kansas FSA has been
given authorization to withdraw a specified amount from deposit accounts at
First Kansas FSA as payment shares, the amount authorized for withdrawal shall
not otherwise be available for withdrawal by the undersigned. I ACKNOWLEDGE THAT
THIS SECURITY IS NOT A DEPOSIT OR ACCOUNT AND IS NOT INSURED OR GUARANTEED BY
THE SAIF, THE FDIC OR THE FEDERAL GOVERNMENT.
Under penalty of perjury, I certify that the Social Security or Tax ID Number on
this Stock Order Form is true, correct and complete and that I am not subject to
back-up withholding.
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Sign Below (You must also read and sign the Certification on the reverse side to
purchase stock).
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Sign and date the form. When purchasing as a
custodian, corporate officer, etc., include
your full title. An additional signature is ===========================================================
required only when payment is by withdrawal
from an account that requires more than one
signature to withdraw funds. YOUR ORDER WILL BE X__________________________________________________________
FILLED IN ACCORDANCE WITH THE PROVISIONS OF THE Authorized Signature Title (if applicable) Date
PROSPECTUS. THIS ORDER IS NOT VALID IF NOT SIGNED
ON THE FRONT AND BACK.
If you need help completing this form, you may X__________________________________________________________
call the Stock Center at ( ) _________ Authorized Signature Title (if applicable) Date
____________________________________________________============================================================
x
Names(s) on Accounts Account Number Names(s) on Accounts Account Number
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GUIDELINES FOR REGISTERING STOCK
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For reasons of clarity and standardization, the stock transfer industry has
developed uniform stock ownership registrations which we will use in issuing
your stock certificate. Common ownership registrations are explained below. If
you have any questions about how your First Kansas Financial Corporation stock
should be registered, see your legal advisor.
To ensure correct registration, please follow the instructions for the
ownership you select:
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GENERAL INSTRUCTIONS: o Include the first name, middle initial, and last name of each person listed. Avoid the use of an
initial in place of the first name.
o Do not use titles such as ("Mr.," "Mrs.," "Dr.," etc.)
o Omit words that do not affect ownership rights such as "special account" "personal property,"
etc.
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INDIVIDUAL: Instructions: Print the first name, middle initial, and last name of the person in whose name the
stock is to be registered. You may not list beneficiaries for this ownership.
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JOINT TENANTS: Joint Tenancy with Right of Survivorship identifies two or more persons as owners of the stock.
Upon the death of one of the owners, ownership automatically passes to the surviving tenant(s).
Instructions: Print the first name, middle initial, and last name of each joint tenant. You may not
list beneficiaries for this ownership.
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TENANTS IN COMMON: Tenants in Common identifies two or more persons as owners of the stock. Upon the death of one
co-tenant, ownership of the stock passes to the heirs of the deceased co-tenant and the surviving co-
tenant(s).
Instructions: Print the first name, middle initial, and last name of each co-tenant. You may not list
beneficiaries for this ownership.
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FIDUCIARIES: Generally, fiduciary relationships (such as Conservatorship, Legal Trust, Guardianship, etc.) are
established under a form of trust agreement or are pursuant to a court order. Without a legal
document establishing a fiduciary relationship, your stock may not be registered in a fiduciary
capacity.
Instructions: On the first "NAME" line, print the first name, middle initial, and last name of the
fiduciary if the fiduciary is an individual. If the fiduciary is a corporation, list the corporate title on
the first "NAME" line. Following the name, print the fiduciary "title" such as conservator, personal
representative, etc.
On the second "NAME" line, print either the name of the maker, donor or testator or the name of
the beneficiary. Following the name, indicate the type of legal document establishing the fiduciary
relationship (agreement, court order, etc.)
In the blank above "Adoption Date," fill in the date of the document governing the relationship.
The date of the document need not be provided for a trust created by a will.
EXAMPLE OF A FIDUCIARY REGISTRATION:
John D. Smith Trustee for Tom A. Smith Under Agreement Dated 6/6/74.
PLEASE NOTE THAT "TOTTEN TRUST" AND "PAYABLE ON DEATH" OWNERSHIPS MAY
NOT BE USED IN REGISTERING STOCK.
For example, stock cannot be registered as "John Doe Trustee for Jane Doe" or "John Doe Payable
on Death to Jane Doe."
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UNIFORM GIFTS TO For Kansas residents and residents of many states, stock may be held in the name of
MINORS ACT/UNIFORM a custodian for the benefit of a minor under the Uniform Transfers to Minors Act. For
TRANSFERS TO MINORS: residents of some other states, stock may be held in a similar type of ownership under the Uniform
Gifts to Minors Act of the individual states. For either ownership, the minor is the actual owner of
the stock with the adult custodian being responsible for the investment until the minor reaches legal
age.
Instructions: If you are a Kansas resident and wish to register stock in this ownership, check
"Uniform Transfers to Minors Act." For other states, see your legal advisor if you are unsure about
the correct registration of your stock.
On the first "NAME" line, print the first name, middle initial, and last name of the custodian with
the abbreviation "CUST" after the name.
Print the first name, middle initial, and last name of the minor on the second "NAME" line.
Only one custodian and one minor may be designated.
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NASD AFFILIATION: Please refer to the NASD AFFILIATION statement on the face of this form. If applicable, initial
where indicated and check the box. The National Association of Securities Dealers, Inc.
Interpretation With Respect to Free-Riding and Withholding (the "Interpretation") restricts the sale
of a "hot issue" (securities that trade at a premium in the aftermarket) to NASD members, persons
associated with NASD members (i.e., an owner, director, officer, partner, employee or agent of a
NASD member) and certain members of their families. Such persons are requested to indicate that
they will comply with certain conditions required for an exemption from the restrictions.
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CERTIFICATION: I/WE ACKNOWLEDGE THAT THIS SECURITY IS NOT A DEPOSIT OR AN ACCOUNT
AND IS NOT FEDERALLY INSURED, AND IS NOT GUARANTEED BY FIRST KANSAS
FSA OR BY THE FEDERAL GOVERNMENT.
If anyone asserts that this security is federally insured or guaranteed, or is as safe as an insured
deposit, I/we should call the Office of Thrift Supervision Regional Director, ________ Regional
Office, at ( ) ________.
I/We further certify that before purchasing the common stock, par value $0.10 per share, of First
Kansas Financial Corporation, I/we received a _____ that contains disclosure concerning the nature
of the security being offered and describes the risks involved in the investment, including, among
other (1)___________; (2) ____________; (3) ___________; (4)_________; (5)__________ ; (6)
__________; (7)_____________; (8)______________; (9) ___________; (10)__________ ; (11)
__________________; (12)________________; (13)_____________; (14)_____________ ; and
(15)_________________. See "Risk Factors" on pages __ through __ of the __________.
SIGNATURE: ____________________ SIGNATURE: _________________________
PRINT NAME ____________________ PRINT NAME:_________________________
SIGNATURE: ____________________ SIGNATURE: _________________________
PRINT NAME:_____________________ PRINT NAME:_________________________