This serves as notification of a change in my automatic
payment information. Effective immediately, you are
authorized to establish an automatic payment deduction
from my Bangor Savings Bank account.
Step Two
Automatic Payments Authorization
If you have any questions,
we will gladly talk you through it.
1.877.Bangor1
BILLER INFORMATION
NAME OF COMPANY/ORGANIZATION PHONE
ADDRESS
CITY STATE ZIP
CUSTOMER INFORMATION
NAME BILLING ACCOUNT NUMBER
ADDRESS
CITY STATE ZIP
BANK ACCOUNT INFORMATION
Bangor Savings Bank Routing Number: 211274382
Bank Account Number: ___________________________________________________________
❒
Checking
❒
Savings
AUTHORIZATION
Account Holder Signature:_________________________________________________________ Date:__________________
Account Holder Signature:_________________________________________________________ Date:__________________
Please acknowledge your receipt of this notice by sending confirmation of this change to the address
listed under CUSTOMER INFORMATION. Please notify customer immediately if this form is not sufficient
to complete the requested change.
The company or organization that receives automatic payment.
The person from whose account the automatic payment is made.
Member FDIC Equal Housing Lender
© Bangor Savings Bank 2006
