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Automatic Payment Request Form

Please accept this letter as notification that I have established a new checking and/or savings account at SmartBank. I would like the following payment to be automatically debited from the SmartBank account listed below.

Automatic Payment Request

Establish Automatic Payment Change my existing Automatic Payment

Automatic Payment Information

Company Name: Company Account #: Payment Amount: $

Attach Voided Check Here

Personal Information

Name: Mailing Address:

City: State: Daytime Phone #: Zip:

SmartBank Account Information

Account Type: Checking Savings Money Market SmartBank Acct. #

I Authorize: The company listed to initiate withdrawal of my funds from the above SmartBank account. SmartBank to to debit funds from my account. This authorization to remain in effect until I send written notice of change or cancellation.

Signature:

Date:

smartbank.net

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865.453.2650

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2430 Teaster Lane Pigeon Forge, TN 37863

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