HSAACHAUTH-12/17 Member FDIC Page 1 of 1
BANK
NAME _Cattle Bank & Trust
I (we) hereby authorize Cattle Bank & Trust to initiate DEBIT / CREDIT (circle one) entries to my (our)
CHECKING / SAVINGS (circle one) account indicated below on a MONTHLY / SEMI-MONTHLY / WEEKLY / BI-
WEEKLY / DAILY/ ANNUAL / SEMI-ANNUAL (circle one) basis in the amount of $_________________________ for the
purpose of _____Health Savings Account Funding____.
The first transfer will begin on __________________________ (date).
If applicable, this agreement will terminate on _________________________ (date).
BANK
NAME ________________________________________ BRANCH _________________
CITY__________________________________ STATE _______________ ZIP ___________
ABA NO.______________________ ACCOUNT NO. ______________________________
This authority is to remain in full force and effect until the company and the bank listed above have received written notification
from me (or either of us) of its termination in such time and in such manner as to afford the company and the bank a
reasonable opportunity to act on it.
*****ATTACH VOIDED CHECK TO THIS AUTHORIZATION FOR VERIFICATION*****
NAME(S) __________________________________________ SSN/TIN_________________
(PLEASE PRINT)
DATE___________________ SIGNED X ______________________________________
SIGNED X ______________________________________
Cattle Bank & Trust
Health Savings Account
Authorization Agreement for Preauthorized Payments
