CASH CARD

FIRST NAME:*
MIDDLE INITIAL:
LAST NAME:*
MAILING ADDRESS:*
CITY:*
STATE:*
ZIP CODE:
EMAIL ADDRESS: *
PHYSICAL ADDRESS: (IF DIFFERENT THAN MAILING ADDRESS)
CITY:
STATE:
ZIP CODE:
TELEPHONE NUMBER:*
DATE OF BIRTH:*

MonthDayYear
Date
SOCIAL SECURITY NUMBER:*
This authority will remain in full force and effect until written notification from me of its termination or change. If an error of under deposit or over deposit is distributed into my account, I authorize Citizens Bank and Trust to make correcting adjustment.
Signature* Date*
Should be Empty: