Automatic Transfer Application

Central Bank

Automatic Transfer Authorization
As used in this authorization, “we” and “us” means the owner of the accounts identifies below. “You” and “yours” means the depository instituion names below.
Amount $

Total amount dueAs Needed (will be charged 5 days after the invoice date)
Amount to be transferred*
Frequency:

WeeklyBi-WeeklyMonthly
Frequency: Weekly, Bi-Weekly, or Monthly*
Effective (starting) date*

MonthDayYear
Date
Termination date*

MonthDayYear
Date
Debit Account Information:
Account Holder Name*
Bank Name*
Routing Number*
Account Number*
Bank Account Type: Savings, Checking, Other (please specify)*
These accounts remain subject to their individual terms and conditions, which are not modified by this authorization. If a transfer is made from a savings account, you retain the right to require not less than 7 days written notice of the withdrawal. If no termination date is specified above, this authorization will remain in effect until terminated by any one of us. You may terminate this authorization by giving us 15 days written notice at the address stated below. Notice to any one of us, is a notice to all of us.
Signature*

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Date*

MonthDayYear
Date
How did you hear about us?*

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Central Bank

600 Lake Avenue N

Storm Lake, IA 50588
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Central Bank