Automatic Payments/Transfers Request

	TIB BANK

Automatic Payments/Transfers Request




Personal Information

First Name:
Last Name:
Street Address:

City:
State:
Zip:
Daytime Phone Number:	(NNN) NNN-NNNN
Biller Information
Name of Biller/Company:
Street Address:

City:
State:
Zip:
Account Number with Biller:
I want to:

Establish New Automatic Payment Establish New Automatic Transfer	Change Existing Automatic Payment Change Existing New Automatic Transfer

Please forward the balance in the account stated above the address

TIB Bank Account

Routing & Transit (ABA) Number:

| Account Number:

| A Voided check has been attached

Employer Information

Name of Employer:

Address of Employer
Headquarters:

City:

State:

Zip:

Employer Phone Number:

(NNN) NNN-NNNN

I authorize the Biller/Company indicated above to initiate payments/transfers from my TIB Bank checking account. These instructions shall
remain in effect until I provide new written notice. Please contact me at the phone number listed above if you have any questions.

____________________________________________ Authorized Signature	________________________ Date
____________________________________________ Authorized Signature	________________________ Date