Netconnect 117 East First PO Box 306 Monticello, IA 52310
Automatic checking withdrawal authorization.
Please print out, fill out, and return this form to Netconnect. If you have any questions or just need help
completing the form, call 319-465-6336 or 319-927-2930 for assistance.
______________________________________________________________________
First Name Initial Last Name
______________________________________________________________________
Address City State Zip Code
______________________________________________________________________
Last four digits of your Social Security Number Mothers Maiden Name
(___)__________________________________________________________________
Home Phone E-mail address
Tell us about the checking account from which your payment is to be deducted
______________________________________________________________________
Bank Name City State
RTN:(the 9 digits preceding the colon on the bottom of your check)_________________
Checking account number (all digits following the colon)__________________________
$19.95 on twenty fifth (25th) day of the month starting __________20___ Month
We Need your signature
X______________________________________________________________________
SIGN HERE
TODAYS DATE
By signing above I am authorizing Netconnect to initiate debit entries to my account. This
authorization shall remain in full force and effect until Netconnect has received notification from
me to terminate this Authorization in such time and such manner as to afford Netconnect and my
depository institution a reasonable opportunity to act on it. Such debits shall initially be
made from the account described above.