Authorization Agreement for FB&T One-Time ACH Loan Payment and $5.00 Transfer Fee

I (we) hereby authorize First Bank and Trust Company, hereinafter called COMPANY, to initiate a debit entry to my (our) account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same account. I (we) acknowledge that the origination of an ACH transaction to my (our) account must comply with the provisions of U.S. law.

Required Field

Debit

Account Type

Checking
Savings

Depository Name Branch City State Zip Code Routing Number Account Number

This one-time authorization for the loan payment amount plus the $5.00 transfer fee will need to be submitted and received by COMPANY no later than 10:00am CST for same-day payment. If received after that time, or on a non-business day, it will be transmitted the following business day. If you choose to cancel a future-dated transaction, COMPANY must be notified in writing no later than 10:00am CST on the business day before the payment date. The fee will not be refundable. While we are not responsible for late payments, we will make our best efforts to remedy.

Credit

Loan Number Payment Date Payment Amount + $5.00 Fee = Total Debit Amount Address City State Zip Code

Certification

I certify under penalties of perjury that the statements contained in this section are correct.

By submitting this application, I certify that I/we gave truthfully and fully provided the information required and that I am at least 18 years of age and live in the US.

Signature Date Applicant's Signature