Direct Deposit

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT

TRINITY LUTHERAN CHURCH AND SCHOOL - HOFFMAN, IL

I (We) ____________________________ Hereby authorize Farmers State Bank of Hoffman to initiate debit entries to my (our) account (__)Checking or (__)Savings indicated below at the depository financial institution named below to be credited to the Trinity Lutheran Church & School, Hoffman, Illinois 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)every 14 days _____(semi-monthly)twice monthly

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PLEASE ATTACH A VOIDED CHECK TO THIS FORM

Bank Name ____________________________________

Bank Routing Number _________________________

City & State ___________________________________

Customer Name _______________________________________

Account Number ____________________ Dollar Amount $____________

Starting Date __________________________

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