Direct Deposit Form Instructions: 1, Complete, sign and date this form; make additional copies as necessary, 2. Suomi this form fo each company/organization that you wish to establish or change airect deposit directions for your account, Keep a copy for yoursell, Company /Organization Making Direct Deposit Company/Organization Name. Adaires city si 3 Direct Deposit Request to First State Bank Ihave recently changed banks and would Ike lo estatlish/change my direc instructions. Eflective immediately please discontinue my current ditect deposit and/or storl making the folowing automatic deposits into my Fist Stale Bank accounts) First State Bonk Began a 2.0. Box 305 Reins ve stpointe, Ml 48021 Phone #: 866.372.1275 ABA Rouling #: 072410165 o Establish Direct Deposit oF = Change My Existing Direct Deposit Note: You can make direct deposits to move than one account. Account Type: 2, Account Type: 1 Fist Slate Bank Checking 1D Fist Slate Bank Checking 1D First State Bonk Savings 0 Fist State Bank Savings Account Number: Ac Number Amount $ of % (circle one} Amount $ of % (cele one} + Contact Information and Signature Nome Employee iO# Address city State tp Daylime Phone # Please acceot this as my autharization to make direct deposits as ins ony questions about this request, please call me at the phone number cbave, Signature Dele Print Nome Fist State Bank Personal Switch ki