Automatic Payment

Change Form

Date_____________ Company Name____________________________________

Company Address____________________________________________________

City_______________________ State_____ Zip Code____________________

You are currently withdrawing $_________ on ____________from the following account: (date)

Old Bank __________________________________________________________

Routing Number__________________ (first 9 characters on the bottom left side of your check)

Account Number__________________ (last numeric characters on the bottom right side of your check)

Please stop making withdrawals from this account on ________________

(date)

and start making withdrawals from my new account listed below on_____________

(date)

New Bank: First National Bank in Pratt____

Routing Number 101101662 Account Number ______________________

Please contact me at the following phone number if you have any questions:

Phone # ____________________ Phone # ____________________

(Day) (Evening)

Sincerely,

Signature _________________________ Name ____________________________

(Please print)

Address____________________________________________________________

City_______________________ State_____ Zip Code____________________