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Program

Authorization To Change

Automatic Payment

Complete this form for each company or organization with whom you have arranged for automatic payments. Call First National Bank at 979-865-3181 for additional forms, or make copies of this form.

Information relating to my current checking account at:

Please print name of financial institution

______________________________________________________________________________

Date of draft payment

Checking account number (Please attach voided check)

Name on account

I hereby authorize automatic payment from my checking account at First National Bank of Bellville, P. O. Box 128, Bellville, Texas 77418.

Company to receive this form Address of Company

My/Our account number at this company

New ABA Routing Number: 113103687

My checking account number

My/Our signature(s)

______________________________________________________________________________

Daytime telephone number

Date

(Please complete, sign and bring in to First National Bank)

If there are questions, or assistance is needed in completing the form, please call Brenda or Bertha at 1-800-235-5737 or e-mail to mailbox@fnbbellville.com.