Automatic Draft Payment Selection Form-mysite

Automatic Draft Payment Selection Form

(* required information)

Former School District or Employer:

First Name:

Last Name:

Mailing Address including City, State, and Zip Code:

Phone Number(s):

Email:

Bank Routing Number (9 digits):

9

Bank Account Number:

20

Type of Account:

Checking Account

Savings Account

Please send email notifications each time my account is debited (optional). The emails will come from Southside Bank.

Include a message to Mandy (optional):

Today's Date:

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