Internal Recurring Transfer Form

This agreement is to authorize you to make electronic funds transfers to and from my (our) deposit accounts which I (we) have with you.
First Name*
Last Name*
Debit Account Number*
Checking   Savings
Credit Account Number*
Checking   Savings
Starting Date*
I (we) understand that this authorization will remain in full force and effect until I (we) notify First Bankers Trust in writing, at PO BOX 3566 Attn: Deposit Ops Quincy, IL 62305 or by calling 877-228-8001, that I (we) wish to revoke this authorization. I (we) understand that First Bankers Trust requires at least (3) days prior notice in order to cancel this authorization.

By submitting this agreement, I (we) authorize you to make the automatic transfer of funds as outlined above.

* required field