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Automatic Bank Draft

Information about you:

First Name:

Middle Initial:

Last Name:

Account Number:

Address:

City:

State:

Zip:

Phone number (HOME):

Phone number (WORK):

Cell Phone number:

E-mail address:

Person making request:

Information is being sent to a secure site.

I hereby authorize Farmers RECC and the Financial Institution designated to make automatic payments from the account I have specified on this authorization form. I understand that this authority is to remain in effect until cancelled by me, FRECC, or the financial institution designated.