Port Washington State Bank

Automatic Payment Authorization

Complete this form to have your routine monthly payments automatically transferred from your Port    Washington State Bank checking account.  Examples include:

	□     Safe Deposit Box                                    □     Home, Auto or Life Insurance □     Gas or Electric □     Telephone or Cellular

 

□  

□     Cable Television □     Internet Service Provider

Mortgage                                     

□   Home Equity                                    

□   Auto Loan or Lease                

□   Credit Card                             

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                          City, State, Zip                             Phone #

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                                City, State, Zip                       Phone #

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                                City, State, Zip                       Phone #

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                                City, State, Zip                       Phone #

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                                City, State, Zip                       Phone #

 

________________________________ __________________    ________   _______/_______

Payee (Full name of company)                    Account #                        $ Amount    PAY on Day/Month

 

___________________________________________________    __________________________

Address                                                City, State, Zip                       Phone #

 

Access your Port Washington State Bank accounts through:

• Internet banking with bill pay at www.pwsb.com

• 24-hour Automated Telephone Banking at (800) 487-7972

• Offices located in Port Washington, Saukville, Belgium, Fredonia and Grafton