Direct Deposit

Change Form

Date_____________ Company Name____________________________________

Company Address____________________________________________________

City_______________________ State_____ Zip Code____________________

You are currently depositing my _________________________________________

LIST DEPOSIT TYPE (paycheck, Social Security check, etc.)

into the following account:

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 start making this automatic deposit into my new account _______________

(effective 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____________________