Overdraft Privilege Opt Out Form

To revoke your participation in our discretionary Overdraft Privilege program, please complete this form.

By clicking the submit button below your request will be emailed securely to the bank. You may also print this form and present at one of our bank branches or mail to First Bankers Trust Company, P.O. Box 3566 Quincy IL 62305, Attn: Bookkeeping. Additionally, you may call 217-228-8000 and inform a Customer Service Representative that you do not want to participate in our discretionary Overdraft Privilege program.

Last Name or Business Name*
First Name
Phone Number*
Account Number*
Account Number
Account Number
To revoke authorization on more than three accounts, please submit an additional form.

I/We wish to revoke participation in the Overdraft Privilege program.


By submitting this form, I/We agree to the information provided above.

* required field