First State Bank of Livingston

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Internet Banking Authorization

Please fill out the form, mail to P.O. Box 1277, Livingston, Texas 77351, fax to 936-327-3894, or return to any of our 4 convenient locations.

Internet Banking

Access account balances, transfer money, cancel lost or stolen cards, pay bills, and conduct common banking tasks online. You may also enroll online for E-statements, mobile web, and SMS text messaging.

Bill Payment

You may sign up for "Bill Payment" online. Once you access NetTeller TM!, click "Bill Payment" in the top menu bar. Click "Add Account". Then select the account from the dropdown box that you want to pay your bills from and submit. Choose the check number you want the bill payment checks to begin with from the dropdown box. Please read the disclosures and click "Accept" or "Decline".

I (We) would like the institution to establish the following person as an Internet banking user for the indicated account(s). I (We) understand that Internet access must be carefully guarded and controlled. Security features such as passwords must be carefully safeguarded to insure that no unauthorized access or transactions can occur. I (We) understand that my (our) failure to safeguard passwords can result in transactions which I (we) will be held liable for. I (We) also understand the increased importance of reviewing my (our) banking statements and notices as soon as received.

Name *

2nd Name *

SSN *

2nd SSN *

Email *

Address *

City *

State *

Zip *

Primary Phone *

Secondary Phone *

Access All Accounts List Accounts You Wish to Access

Account Numbers You Wish To Access on NetTeller

Transfer Funds From This Account

What do you wish to call this account? i.e. Car Loan, Home Checking, etc.

Account 1

Account 1 You Wish To Access on NetTeller

Transfer Funds From Account 1?

Yes No

What do you wish to call this account? i.e. Car Loan, Household Checking, etc.

Account 2

Account 2 You Wish To Access on NetTeller

Transfer Funds From Account 2?

Yes No

What do you wish to call this account? i.e. Car Loan, Household Checking, etc.

Account 3

Account 3 You Wish To Access on NetTeller

Transfer Funds From Account 3?

Yes No

What do you wish to call this account? i.e. Car Loan, Household Checking, etc.

Account 4

Account 4 You Wish To Access on NetTeller

Transfer Funds From Account 4?

Yes No

What do you wish to call this account? i.e. Car Loan, Household Checking, etc.

Signatures on an account indicate approval for the above named person to have Internet access to the account.

(Customer Signature)

(Date)

(Customer Signature)

(Date)

For institution use only. Institution personnel should initial and complete the following as applicable:

The signature cards of the above accounts were reviewed and the customer is a proper signatory on the account.

(Initials)

The customer's accounts were entered onto NetTeller.

(Initials)

Primary CIF:

NetTeller I.D. Number:

7021

Date:

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First State Bank FFIEC Report

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