Automatic Transfer Application

Pocahontas State 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 to be transferred*
Frequency*
Effective (starting) date*

MonthDayYear
Date
Termination date*

MonthDayYear
Date
Debit Account Information:
Bank Name*
Routing Number*
Account Number*
Account Title (Name)*
Phone Number*
Type*
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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Pocahontas State Bank

233 N Main, P.O. Box 130

Pocahontas, IA 50574
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Pocahontas State Bank