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.