AUTHORIZATION TO CHANGE AUTOMATIC PAYMENT |
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| Name of Payee: | __________________________________________ |
| Payee Address: | __________________________________________ |
| My Name: | __________________________________________ |
| My Address: | __________________________________________ |
| My SSN | __________________________________________ |
| I plan to close my checking account at: | __________________________________________ |
| Account #: | __________________________________________ |
| Effectively immediately, I authorize payment from my new checking account at: | |
First National Bank |
|
| My New Account #: | __________________________________________ |
| New Routing / ABA #: | __________________________________________ |
| I have attached a voided check to verify the new account information. I understand it may take up to 30 days for the receiver to process this request. | |
| Signature: | __________________________________________ |
| Phone #: | __________________________________________ |
| Date: | __________________________________________ |