Bill Pay Express Application

We are here to help you. Complete the form below and click "Submit." We check Secure Form submissions daily and will respond appropriately. For your security, we will contact you prior to activating this service. If you have questions, please contact us during regular business hours at (319) 668-2525 or send us a secure message.

*Indicates Required Field

Name
First *
 Middle
Last *
 

Address
Street *
 City *
 State *
Zip *
 Email *
 

Phone
Day Phone *
() - 		Evening Phone
() -
 

Security
Social Security # *
- - 		Date of Birth *
/ / 		Mothers Maiden Name or Positive ID Word *
 

Account
You must have a checking account with Farmers Trust in order to use the Bill Pay Express. Please indicate your checking account number below.
Account Number *