Personal

Overdraft Services Disclosure and Consent Form

Complete all information below and click "Submit":

I want Farmers State Bank to authorize and pay overdrafts on my ATM and everyday debit card transactions.
I do not want Farmers State Bank to authorize and pay overdrafts on my ATM and everyday debit card transactions.


Last 4 digits of SSN: (xxxx)
Date: (xx/xx/xxxx)
Phone Number: (xxx) xxx-xxxx

You must list the last 4 digits of your account number for each account you choose to have us authorize and pay overdrafts.

Account 1 Number: (xxxx)
Account 2 Number: (xxxx)
Account 3 Number: (xxxx)
Account 4 Number: (xxxx)

Right to Revoke Consent
If you have given your consent to have Farmers State Bank authorize and pay overdrafts on ATM and everyday debit card transactions, you may revoke that consent at any time by notifying Farmers State Bank as follows:

1009 Peoples Sq.
Waterloo, IA 50702

You may also call 1-877-372-1879
(If this is a joint account, anyone of you may revoke the consent on behalf of the other account holder(s).)