AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT TRINITY LUTHERAN CHURCH - HOFFMAN, IL TRINITY LUTHERAN SCHOOL - HOFFMAN, IL

I (We) _____________________ hereby authorize Farmers State Bank of Hoffman, to initiate debit entries to my(our) ____checking  or _____savings account indicated below at the depository financial institution named below to be credited to the Trinity Lutheran Church & School, Hoffman, IL  account ____________________________. This debit will take place on the same day each month as indicated until written notice is received from me to revoke said deposit. _____ monthly   _____weekly     _____bi-weekly     _____semi-monthly

PLEASE ATTACH A VOIDED CHECK TO THIS FORM. Customer Name ________________________________           Starting Date:  ________________________________ Bank Name: ____________________________________ Bank Routing Number:  ____________________________            Account Number:  ____________________________ City & State:  ___________________________________            Dollar Amount:  _______________________________ Authorized Signature:  ______________________________________________________________________________

Please return this form to: Farmers State Bank of Hoffman PO Box 380 Hoffman, IL  62250 or Trinity Lutheran church 8700 Huey Rd Box 200 Hoffman, IL  62250