AUTHORIZATION TO CHANGE AUTOMATIC PAYMENT

Name of Payee: __________________________________________
Payee Address: __________________________________________
My Name: __________________________________________
My Address: __________________________________________
My SSN __________________________________________
I plan to close my checking account at: __________________________________________
Account #: __________________________________________
 
Effectively immediately, I authorize payment from my new checking account at:

First Heritage Bank
801 S. Fremont
Shenandoah, IA 51601
Phone: 712-246-5118
Fax:712-246-3554
www.fhbshen.com

 
My New Account #: __________________________________________
New Routing / ABA #: __________________________________________
 
I have attached a voided check to verify the new account information. I understand it may take up to 30 days for the receiver to process this request.
 
Signature: __________________________________________
Phone #: __________________________________________
Date: __________________________________________