Overdraft Protection Form

First Name*
Last Name*

I/We request and authorize the First Bankers Trust Co. N.A. to charge my/our

Checking  Savings

Account # *

when my/our checking account balance falls below a minimum of $0.00 and transfer and deposit these funds in my/our

Checking Account # *

The amount which can be charged and so transferred shall equal the amount necessary to cause said checking account balance to equal or exceed said minimum balance. All transfers shall be made in multiples of $100.00. Because of the convenience this service affords, I/we also authorize the Bank to charge my/our checking account $5.00 for each transfer.

In addition, I/we agree to maintain a sufficient balance in my/our savings account to cover the transfers requested by the above authorization. If the balances in my/our savings account are insufficient to cover the transfers authorized, the Bank may cancel this authorization immediately without notice.

Upon 30 days written notice to you, the Bank may amend this authorization in any respect (including without limitation the Fee for this service). Such notice shall be properly given when enclosed with your checking account statement. If this authorization needs to be amended because of a change in State or Federal Regulations, the change shall be effective immediately without notice.

You or the Bank may cancel this authorization upon written notice to the appropriate party. Such notice shall be effective immediately.

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

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