Electronic Statement Consent Form

Name(s) on Account:

First:

Last:

First:

Last:

Current Statement Mailing Address:

Address:

City:

State:

Zip:

Phone Number:

Email Address:

Checking Account numbers you wish to retrieve statements for through Internet Banking:

1st

2nd

3rd

4th

5th

6th

By signing below you represent that you have read, understood and agreed to the terms and conditions of the PAPERLESS INTERNET STATEMENT(S) AGREEMENT and that you have caused this Consent Form to be executed and warrant that you or your respective signatories, whose signatures appear below, have been and are as of the date of this Form, duly authorized by all necessary action in accordance with their governing instruments, if applicable, to execute this Consent Form. Finally, by signing below, you understand that you have chosen to discontinue receiving paper statement(s), cancelled checks, deposit slips, etc. on the designated accounts.

AGREED TO AND ACCEPTED:

Signed By:______________________________________

Signed By:______________________________________

Printed Name:______________________________________

Printed Name:______________________________________

Date:

Print this form and bring it to any of our locations so we can get your E-Statements setup.