COMMUNITY STATE BANK

BILL PAYMENT AUTHORIZATION

Applicant Name ___________________________________________

Account to Pay From: _______________________________________

Please enroll me in Community State Bank Online Bill Payment service. I authorize Community State Bank to charge my designated check account for all bill payments that I establish through Online Banking and any charges and fees that I may incur with use of this service. I agree that the use of Community State Bank Online Bill Payment service is subject to the Terms and Conditions contained in the Online Banking Agreement and the fees as listed in my account disclosure.

____________________________________________________ _________________
Applicant Signature Date

Contact Methods:

Home Phone: ___________________________________

Business Phone: _________________________________

Email: ________________________________________________________________________

All payments should be scheduled approximately 5-7 business days in advance of due date to allow for delivery.

You will receive notification by email when Bill Payment is available to you, typically within one or two business days after we receive this authorization.

Please return this form to your local branch, or fax to 989-865-6561
Online Banking Customer Assistance 989-865-9945

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PORT & Line Number ___________________________

Signature verified by ___________________________ Date ____________________

Acct Disclosure given by _________________________ Date ____________________

Caller Record Changed by ________________________ Date ____________________

Customer notified by ____________________________ Date ____________________