Additional ATM & Debit Card Payment Authorization Form

Opt-In or Opt-Out?
- Opt-In - I want Independent Financial to authorize and pay overdrafts on my ATM and everyday debit card transactions. (Applies to existing bounce protection customers.)
- Opt-Out - I do not want Independent Financial to authorize and pay overdrafts on my ATM and everyday debit card transactions.
OK Opt-In or Opt-Out? is required

(This selection will not affect your existing Bounce Protection coverage. If you would like to waive all Bounce Protection from your account, click here.)

Name
OK Name is required

Please only enter the last 4 digits of your accounts number(s).

Last Four Digits of your Account #
OK Please only enter the last four digits
Last Four Digits of your Account #
Optional OK Please only enter the last four digits

You will receive confirmation of your designated response by U.S. Mail.

CALL: If you have any questions or would prefer to conduct this change over the phone, please contact Customer Care at 800.460.6634.

OK is required

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Opt-In or Opt-Out?

Are no FDIC Insured	Are not Bank Guaranteed	May Lose Value
Are not Deposits	Are not insured by Any Federal Government Agency	Are not a Condition to Any Banking Serivice or Activity