Direct Deposit Authorization Form (Page 4 of 4) in pdf

Direct Deposit Authorization Form Page 4

Direct Pay Worksheet

To add or change direct payments or transfers from your old account, you’ll need to

contact each payee. To make that process easier and ensure you have all the required

data ready, fill in the information below before contacting payees.

(please print)

Your Name ____________________________SSN _________________

Address ____________________________________________________

City ____________________________ State _______ Zip___________

Some payees may be able to set up recurring payments and transfers using your First

State Bank & Trust Debit Card number and expiration date. This is the easiest way to

make recurring payments and transfers.

Your First State Bank & Trust Debit Card number and expiration date can be found on

the front of your card.

Your First State Bank & Trust Debit Card Number _________________________

Your First State Bank & Trust Debit Card Expiration Date_________________________

Other payees will require that you provide your First State Bank & Trust account number

and our bank routing number. Both numbers can be found on a First State Bank & Trust

check.

See sample below:

Your First State Bank & Trust

routing Number

______081517907__________

Your First State Bank & Trust

account Number

________________________

Fill out the information below before contacting payees:

Add

Change

(check one)

Payee Name____________________________________________________________

Account Number with Payee _______________________________________________

Web Address____________________________ Phone Number __________________