Date (Name of bank) (City or town) (State)

Gentlemen: Attached is Draft No. ______, for $______, issued by the ____________ Insurance Company in payment of ______ loss which damage the buildings on the farm of __________________, of ______________ County, State of ______________.

This draft has been endorsed by the undersigned payees who request that you collect these funds and issue cashier's checks to the following payees for the following amounts:

________________, First Mortgage $______ ________________, Second Mortgage $______ ________________, Third Mortgage $______

The balance only, if any, will be paid to ________________, the owner of the property.

First Mortgagee Second Mortgagee Third Mortgagee Owner