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Business or Individual Requesting Access:
CHANGES REQUESTED:
Add the following accounts to my internet access and allow the transfer options listed:
 
Account Number
Description *
Allow Bill Pay **
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

* No more than 20 characters per account
* Do not repeat Descriptions
* Do not use special characters
* Examples: Checking, Checking 2, Savings, Boat Loan, Line of Credit
** Bill Pay Accounts must be DDA; Savings and Money Market Accounts do not qualify.

Account #: Account #:
Description: Description:
Allow funds transfers from the above account to
the following listed accounts:
Allow funds transfers from the above account to the following listed accounts:
Account #: Account #
Account #: Account #
Account #: Account #
Account #: Account #
Account #: Account #
Account #: Account #
Delete the following accouns from my internet access:
 
Account #: Account #:
Description: Description:
 
Account #: Account #:
Description: Description:
Please Read Before Signing
I certify that the information provided is true and correct. I authorize Citizens State Bank to verify all information regarding this change form and I authorize CSB to alter my access as discribed on all of the accounts I am a signer on listed above. I authorize Citizens State Bank to allow me to set-up Bill Pay, via the internet, on the acount I have requested above. The use of ONLINE BANKING shall be governed by the printed terms and conditions of the ONLINE BANKING AGREEMENT & DISCLOSURE or amendments thereto, as may be established by Citizens State Bank and communicated in writing to me.
Electronic Signature:
Date:
 
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