First State Bank
Tahlequah, OK
Authorization to Change
Direct Deposit/ Automatic Deposits
Print and complete this form to notify each depositor with whom you have arranged for direct deposits to notify them that
you have changed banks and are authorizing the direct deposit to be made to your new First State Bank account. If you
have Social Security deposits, please contact the Social Security Administration directly by calling 1-800-772-1213 or
Visit their website at socialsecurity.gov/ onlineservices.
Attach void check from your First State
To:
Bank of Tahlequah Checking account
below to verify banking information.
Depositor Name
Depositor Address
State
Zip
State
Zip
ATTACH
VOID CHECK
City
Account Number
From:
Customer Name
Customer Address
City
Employee ID Number/Dept. (if applicable)
Please redirect my deposit to my First State Bank of Tahlequah
Checking Account Effective:
Immediately or
Beginning
Routing Number:
Checking Number:
103102193
Authorization
Signature
Name: (please print)
Address:
City:
State
Zip: