AUTHORIZATION TO CHANGE MY DIRECT DEPOSIT |
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| Name of company initiating direct deposit: | __________________________________________ |
| Address of Company: | __________________________________________ |
| My Name: | __________________________________________ |
| My Address: | __________________________________________ |
| My SSN | __________________________________________ |
| I plan to close my checking account at: | __________________________________________ |
| Account #: | __________________________________________ |
Effective immediately, I authorize direct deposit to my new account at: |
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| First National Bank 801 S. Fremont Shenandoah, IA 51601 Phone: 712-246-5118 Fax:712-246-3554 www.fnbshen.com |
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| My New Account #: | __________________________________________ |
| New Routing / ABA #: | __________________________________________ |
| I have attached a voided check to verify the new account information. I understand it may take the company making the direct deposit up to 30 days to process this request. | |
| Signature: | __________________________________________ |
| Phone #: | __________________________________________ |
| Date: | __________________________________________ |