LIBBY

eLectronic Information and Balances BY phone

If you have any questions regarding this application, please call 1-217-645-3434 and ask for Customer Service, or e-mail us.

Last Name

First Name

(Joint Owner - if applicable)
Last Name

First Name

Address

City State Zip -

Telephone

( ) -

Employer Phone

( ) -

Social Security Number Which Identifies Accounts:
- -
(or Federal Employer Identification Number, if applicable, for Business Accounts)
-

Personal Identification Number Desired*:

(must be four numeric digits)
*Complete after printing.

I/We, the undersigned, do hereby authorize The Farmers Bank of Liberty (hereinafter BANK) to assign the above Personal Identification Number(hereinafter PIN) to all accounts, loans, certificates, or other bank services or products which are now or which will be listed under the social security number (or FEIN) listed above, and to allow unlimited access to anyone who has both the correct account number and PIN combination. We understand the BANK does not guarantee against unauthorized access from to anyone who discovers the correct account number and PIN combination and I/We will hold BANK harmless in such instances. I/We agree to notify BANK immediately if my/our PIN is lost or stolen, or if I/we learn that an unauthorized party has gained access to my/our PIN. BANK reserves the right to add additional capabilities, services, features, or benefits to the Libby system without notice, but in most cases, the bank will be proud to let me know what new things Libby can do to make my life easier, such as adding dial-up computer connection capabilities and/or internet access.

Signature of Person Whose Social Security Number Appears Above

Signature of Joint owner, if applicable

Date

Please complete this form, print it, write in desired PIN number, sign, date, and send to:

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The FARMERS BANK of Liberty
1002 North Main
Liberty, IL 62347